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Covid 19 Vaccine Screening And Consent Form Ontario

Covid 19 Vaccine Screening And Consent Form Ontario. (a) the patient and at least 18 years of age; Information about patient (please print)

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(b) the legal guardian of the patient and confirm that the patient is at least 12 years of age (for pfizer vaccine consent only); Or (c) legally authorized to consent for vaccination for the patient named above. ☐ by email ☐ by text/sms ☐ by phone ☐ by mail ☐

(B) Legal Guardian Confirm Is 5 Age (For Pfizer Vaccine Consent Only);

☐ by email ☐ by text/sms ☐ by phone ☐ by mail ☐ (a) the patient and at least 18 years of age; (a) the patient and at least 18 years of age;

Or (C) Legally Authorized To Consent For Vaccination For The Patient Named Above.

(b) the legal guardian of the patient and confirm that the patient is at least 12 years of age (for pfizer vaccine consent only); You may be asked by your employer to screen before going to work each day, regardless of your vaccination status. (a) the patientand at least18 years ofage;

Information About You (Please Print) Name:

The letter templates can be adapted to suit the needs. Vaccine screening and consent form. If you consent to be contacted about research studies, and then change your mind, you may withdraw your consent at any time by c ontacting the ministry of health at.

Consent For Influenza Vaccine For Adults Assessed As Being Incapable Of Giving Informed Consent;

_____ primary care clinician (family physician or nurse practitioner) if indigenous, please indicate which indigenous identity: Information about patient (please print) Last name first name identification (e.g., health card number) gender:

(B) The Legal Guardian Of The Patient And Confirm That The Patient Is At Least 12 Years Of Age (For Pfizer Vaccine Consent Only);

(b) the legal guardian of the patient and confirm that the patient is at least 12 years of age (for pfizer vaccine consent only); Male female other emergency contact information Covid 19 vaccine screening and consent form cdc.

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