Book Your COVID Vaccine

Gender:




Have you received any previous doses of covid vaccine?


Acknowledgement of Collection, Use and Disclosure of Personal Health Information

The personal health information on this form is being collected for the purpose of providing care to you and creating an immunization record for you, and because it is necessary for the administration of Ontario’s COVID-19 vaccination program. This information will be used and disclosed for these purposes, as well as other purposes authorized and required by law. For example,

It will be disclosed to the Chief Medical Officer of Health and Ontario public health unitswhere the disclosure is necessary for a purpose of the Health Protection and Promotion Act.And

It may be disclosed, as part of your provincial electronic health record, to health careproviders who are providing care to you.

The information will be stored in a health record system under the custody and control of the Ministry of Health.