Full Name Email Phone Number Health Card Number Birth Date Injection Screening Questionnaire. Please only check if your answer is "Yes" Do you have symptoms of COVID-19? (e.g. Fever, new onset of cough or worsening of chronic 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) In the past 14 days, did you return from travel outside of Canada or have you been in close contact with someone confirmed as having travelled outside of Canada> Are you immunosuppressed due to disease or treatment, or do you have an autoimmune disorder? Are you or could you be pregnant? Are you nursing / breastfeeding? Do you have any severe allergies such as anaphylaxis to any medication(s), vaccine(s) or food(s) or from an unknown cause? Are you allergic to polyethylene glycol or polysorbate or tromethamine? It can be found in some products such as cosmetics, skin care products, laxatives, cough syrups, bowel preparation products for colonoscopy, and some foods and drinks Do you have any medical conditions that require regular visits to a doctor? Do you have a serious allergy to latex or natural rubber? Do you have a bleeding disorder or are taking blood thinners? (e.g. Warfarin, Aspirin) Have you been hospitalized because of a COVID-19 infection? If yes, were you treated with convalescent plasma or monoclonal antibody? Have you ever fainted after a vaccination or medical procedure? Have you received any other vaccines (not a COVID-19 vaccine) in the past 14 days? Vaccination Consent I, the undersigned patient/legal decision maker, have read or had explained to me information about the vaccine as outlined on the vaccine monograph and in the applicable provincial fact sheet(s) regarding the risk and benefits of this vaccine. I have had the chance to ask questions and answers were given to my satisfaction. I understand the risks and benefits of receiving the vaccine. After getting the vaccine, I agree to wait in the clinic / pharmacy for 15 minutes (or the time recommended by the pharmacist). In the event of anaphylaxis, I, my agent, and/or EMS paramedics will receive a copy of this form. I understand the information contained on this form, may be disclosed to public health authorities or your health care professionals and to other parties for the purpose of adverse event and drug safety reporting, as well as other purposes as authorized and required by law. I further understand that the information will be used for outreach, including second dose reminders, as well as potential subsequent immunization campaigns for flu or a booster COVID-19 immunization campaign. Signature Submit
