registration form – Brinkley Pharmacy

COVIC-19 Vaccine Screening and Consent Form

First Name *

Last Name *

Email *

Identification

E.g :health card number

Sex *

Male
Female
Non-Binary
Preffer not to answere

Primary Care Clinician

(Family Physion or Nurse Practitioner)

Street Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Date of Birth

Is this your first or second dose of the vaccine?

Please answere all question below:

Do you have symptoms of Covid-19 or feel ill today? *

Have you previously had a severe allergic reaction *

(e.g..anaphylaxis to a previous dose of a COVID mRNA vaccine or to any of its components or its container?)

Do you have a suspected hypersensitivity or have you had an immediate allergic reaction (this would include an allergic reaction that occurred within 4 hours that cause hives, swelling, or respiratory distress, including wheezing)to :

A previous dose of an mRNA COVID-19 vaccine *

Any components of the mRNA COVID-19 vaccine(including polyethylene glycol [PEG]) *

Polysorbate(due to potential cross-reactive hypersensitivity with the vaccine ingredient PEG) *

Have you ever had a servere (e.g anaphylaxis) or and immediate allergic reaction to any other vaccine or injectable therapy(e.g intramusular, intravenous, or subcutaneous vaccines or therapies not related to a component or mRNA COVID-19 vaqccines or polysorbates)? *

(this would include an allergic reaction that occured within 4 hourse that cause hives, swelling, or respiratory distress,including wheezing)

Have you ever had a severe allergic reaction(e.g..anaphylaxis)not related to vaccines or injectable medicines - such as allergies to food, pet, venon, environmental, or latex etc.? *

Have you recieved another vaccine(not a COVID-19 Vaccine) in the past 14 days? *

Are you or could you be pregnant? *

Are you breastfeeding *

Do you have any problems with your immune system or are you talking any medication that can affect your immune system *

(e.g. high dose steroide, chemotherapy)?

Do you have an autoimmune disease? *

Do you have a bleeding disorder or are talking medication that could affect blood clotting? *

(e.g. blood thinners)

Have you ever felt faint or fainted after a past vaccination or medical procedure? *

(e.g. blood thinners)

Symptoms of COVID-19 can include fever.new onset of cough or worsening of chronoc cough. shortness of breath.difficulty breathing,sore throat,difficulty swallowing.decrease or loss of smell or taste, chills,headaches, unexplained tiredness / malaise / muscle aches, nausea / vomiting, diarrhea or abdominal pain,pink eye, or runny nose or nasal congestion without other known cause or , for those over 70 years of age. an unexplained or increase number of falls, acute functional decline,worsening of chronic condition or delirium

Polyethylene glycol(PEG) can rarely cause allergic reactions and is found in products such as medications. bowel preparation products for colonoscopy, laxatives, cough syrups, cosmetics, skin creams,medical products used on the skin and during operations, toothpaste,contact lenses and contact lens solution.PEG also can be found in food or drinks,but is not known to cause allergic reactions from foods or drinks. Polysorbate may also cause allergic reactions because of cross-reactivity with PEG.

Consent to Receive the Vaccine

I have Read (or it has been read to me) and I understand the 'COVID-19 Vaccine Information Sheet'.
- I have had the opportunity to ask questions and to have them answered to my satisfaction.
- I have had the opportunity to speak with my primary care provider regarding any special considerations that apply to me in respect of the COVID-19 vaccine.

I consent to receiving the Vaccine *

I consent to receiving the 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 proposes authorized and required by law. For example,

- It will be disclosed to the Chief Medical Officer of Health and Ontario public health units where 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 care providers who are providing care of you.

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

Where a Clinic Site is administered by a hospital. the hospital will collect, use disclose your information as an agent of the Ministry of Health.

I acknowledge that i have read and understand the above statement. *

I acknowledge that i have read and understand the above statement.

You may be contacted by a hospital, local public health unit, or the Ministry of Health for purposes related to the Covid-19 vaccine (for example, to remind you of follow-up appointments and to provide you with proof of vaccination ). If you consent to receive these follow-up communications by email or text/SMS, please indicate this using the boxes below.

I consent to receiveing follow-up communications:

by Email
by text/SMS

Consent to Being Contracted About Research Studies

Many research studies will be conducted in respect of COVID-19 vaccines.

You have the option of consenting to be contracted by researchers about participation in COVID-19 vaccines-related research studies. if you consent to be contacted. your personal health information will be used to determine which studies may be relevant to you, and your name and contact information will be disclosed to researchers. Consenting to be contacted about research studies does not mean you have consented to participate in the research itself. Participating in research is voluntary. You may refuse to consent to be contacted about research studies without impacting your eligibiity to receive the COVID-19 vaccines.

If you consent to be contacted about research studies, and then change your mind. you may withdraw your consent at any time by contacting the Ministry of Health at vaccine@ontario.ca

I consent to be contacted about COVID-19 vaccine related research studies:

by Email
by text/SMS
by Phone
by mail

I do not Consent to be contacted about Covid-19 related research studies:

I do not Consent to be contacted about Covid-19 related research studies:

COVIC-19 Vaccine Screening and Consent Form

Please answere all question below:

Consent to Receive the Vaccine

Acknowledgement of Collection,Use and Disclosure of Personal Health Information

Consent to Being Contracted About Research Studies

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