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Ministry of Health
COVID-19 Vaccine Screening and Consent Form
SCREENING AND CONSENT FORM –COVID-19 Vaccine
Version 1.0 – December 30, 2020
Last Name
First Name
Sex: ☐ Female ☐ Male ☐ Non-Binary ☐ Prefer not to answer
Home Phone
Mobile Phone
Email Address
Street Address
City
Province
Postal Code
Date of Birth (month, day,
year)
Age
Is this your first or second dose of the vaccine? ☐ First ☐ Second
______ / _______ / _______
If second, please indicate the date of the first dose: ______ / ____ / ____ (month, day, year)
Please answer all questions below:
Do you have symptoms of COVID-19 or feel ill today*?,
☐ No ☐ Yes
Have you previously had an allergic reaction to any vaccine (including your first
COVID-19 vaccination if applicable) or any component of the Pfizer-BioNTech or
Moderna vaccine?
☐ No ☐ Yes
Are you allergic to polyethylene glycol (PEG)** which is contained in the vaccine?
Talk with your health care provider if you are known to be allergic to polyethylene glycol** or
have had an allergic reaction from an unknown cause. See below for more details**
☐ No ☐ Yes ☐ Uncertain
Have you received another vaccine (not a COVID-19 vaccine) in the past 14 days?
You will be asked to wait for two weeks from the other vaccine to receive your COVID-19
vaccine
☐ No ☐ Yes
Are you or could you be pregnant? ☐ No ☐ Yes
Are you breastfeeding? ☐ No ☐ Yes
Do you have any problems with your immune system or are you taking any
medications that can affect your immune system (e.g., high dose steroids,
chemotherapy)? Ask the health care provider if you are not sure about your medical conditions
☐ No ☐ Yes
Do you have an autoimmune disease? Ask the health care provider if you are not sure
about your medical conditions
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☐ No ☐ Yes
Do you have a bleeding disorder or are taking medications that could affect blood
clotting (e.g., blood thinners)? Ask the health care provider if you are not sure about your
medical conditions
☐ No ☐ Yes
Have you ever felt faint or fainted after a past vaccination or medical procedure?
☐ No ☐ Yes
* Symptoms of COVID-19 can include 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
or, for those over 70 years of age, an unexplained or increased
number of falls, acute functional decline, worsening of chronic
conditions 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 foods or drinks, but is not
known to cause allergic reactions from foods or drinks
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 consent to receiving the vaccine
The personal health information on this
form is being collected for the purpose of
providing care to you. It will be used and
disclosed for this purpose, as well as other
purposes 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.
☐ I acknowledge that I have read and
understand the above statement.
The hospital, local public health units and
the Ministry of Health may wish to
communicate with you for purposes related
to the COVID-19 vaccine (for example,
communications to remind you of follow-up
appointments, to provide you with proof of
vaccination, and to tell you about research
projects.)
I consent to receiving communications by:
☐ email ☐ phone/SMS
Signature
Print Name
Date of Signature
If signing for someone other than yourself, indicate your relationship to that
other person:
☐ If signing for someone other than myself, I
confirm that I am the parent / legal guardian or
substitute decision maker.
FOR CLINIC USE ONLY
Agent
COVID-19
Product Name
Lot #
Dose
Anatomical Site
☐ Left deltoid ☐ Right deltoid
Route
Intramuscular
Dose #
Date Given
______ / ______ / ______ (m/d/yyyy)
Time Given
____ : ____ am pm
AEFI?
☐ Yes ☐ No
Given By (Name, Designation)
Location
Authorized By
Reason for Immunization
☐ Healthcare worker ☐ Healthcare worker: LTC Home ☐ Healthcare worker: Retirement Home
☐ LTC Home: Resident ☐ Retirement Home: Resident ☐ Advanced age: community dwelling
☐ Other employees in acute care, LTC, RHs ☐ Indigenous community ☐ Adult of chronic health care
Reason Imms Not Given
Healthcare provider: ☐ Determines immunization is contraindicated ☐ Recommends immunization but no consent
received ☐ Determines that immunization will be temporarily deferred
Your dose 2 of 2 is scheduled for:
______ / ______ / ______ (month, day, year) ______ : ______ am pm