Please complete and submit the Covid-19 vaccine consent form below prior to your appointment. A printed version will require your signature when you arrive.
If you answer yes to questions 8, 9 or 10, you must also complete a COVID-19 Immunization Enhanced Consent Form. It is also available online at
manitoba.ca/covid19/vaccine/index.html. Paper copies will also be available at the immunization clinic prior to your appointment.
Information about the immunizations you or your dependent(s) receive may be recorded in the provincial immunization registry. This registry allows your health care providers to find out what immunizations you or your dependent(s) have had or need to have. Information collected in the provincial immunization registry may be used to produce immunization records, or notify you or your doctor if a particular immunization has been missed. Manitoba Health, Seniors and Active Living may use the information to monitor how well different vaccines work in preventing disease. The Personal Health Information Act protects your information. You can have your personal health information hidden from view from health care providers. For more information, please contact your local public health office to speak with a public health nurse.