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COVID-19 Vaccine Waitlist Age 5-11
Pacific Medical Clinic is administering COVID-19 vaccines depending on available supply. Please complete the form below to be placed on our waitlist. You will be contacted once your dose can be scheduled. Completing this form does not mean you are guaranteed a vaccine.
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Email
*
Your email
Are you a patient of Pacific Medical Clinic?
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Yes
No
Last Name
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Your answer
First Name
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Your answer
Gender
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Male
Female
Date of Birth
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MM
/
DD
/
YYYY
Street Address
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Your answer
City
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Your answer
Province
*
Your answer
Postal Code
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Your answer
Health Card Number, with Version Code
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Your answer
Did you receive any COVID-19 vaccines outside of Canada?
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Yes
No
How many doses of COVID-19 Vaccine have you had?
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Choose
0
1
2
3
Please list the name of the vaccine(s) you've received and the date(s) you received them, if applicable.
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Your answer
If you have had one or more previous COVID-19 doses, did you have any side effects after any previous doses (including allergic reactions, heart inflammation -myocarditis/pericarditis) ?
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Yes
No
Are you allergic to polyethylene glycol (PEG), tromethamine or polysorbate?
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Yes
No
Questions and comments
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