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