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COVID-19 Vaccine Consent Form - Province of Manitoba

COVID-19 Vaccine Consent FormSections A, B, C, D and E completed by: Client Parent Legal decision maker Other _____ (on behalf of client) A. Client Information - please printSurname _____ Given Names _____Address of residence _____ City/Town _____ Postal Code _____Phone Number _____ Email _____ Sex Male / Female / X Date of Birth (yyyy/mm/dd) _____ / _____ / _____Manitoba Health Number (6 digits) _____ Personal Health Information Number (9 digits) _____Name of school _____ City/Town _____ Grade _____B. Health History of Client1. Do you have a fever or other symptoms that could be due to COVID-19 ? Yes No If yes, describe _____2. Do you have any known or suspected allergies (examples: food, medications, environmental)? Yes No If yes, describe _____3. Do you have a known or suspected allergy to polyethylene glycol (PEG), polysorbate 80 or tromethamine?

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 and Seniors Care may use the information to monitor how well different vaccines work in preventing disease. The Personal Health Information Act protects your information.

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