Required fields are marked with asterisks (*)

Important

Please only complete this form if:

  1. The person you are submitting for is less than five-years old and received one or more doses of a COVID-19 vaccine outside of Ontario.
    OR
  2. You or the person you are submitting for is five-years of age or older and received a dose of a COVID-19 vaccine outside of Ontario within the last three months.

Before completing this form, please carefully review the following:

  • Do not submit if your record has already been documented by another health unit.
  • Do not submit records of COVID-19 vaccinations received in Ontario. This form is for COVID-19 vaccination records received outside of Ontario only. After assessment, valid vaccine records will be added to the provincial COVID vaccination system.
  • Do not submit records if you are a visitor to Ontario (e.g. visiting less than one year, except for international agricultural workers and international students).
  • This form is for Durham Region residents only. If you live outside of Durham Region, contact your public health unit. Find your public health unit.
  • We cannot accept American CDC cards as proof of vaccination. Please contact the clinic who provided your vaccination and request additional proof of vaccination (e.g., an enhanced certificate from the region where your record is from).
  • Proof of vaccine certificates without a QR code from health authorities where enhanced vaccine certificates with QR codes are available will no longer be accepted. Visit covid-19.ontario.ca/verify for a list of health authorities issuing enhanced vaccine certificates.
  • This form is not for travel documentation purposes. If you are required to submit your COVID-19 vaccination records for travel purposes, please visit ArriveCAN for more information.

Out of Province COVID-19 Immunization Form

Acknowledgement of collection, use and disclosure of personal health information

The personal health information on this form is being collected for the purpose of providing care to you and creating an immunization record for you, and because it is necessary for the administration of Ontario’s COVID-19 vaccination program. This information will be used and disclosed for these purposes, 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. And it may be disclosed, as part of your provincial electronic health record, to health care providers who are providing care to you. The information will be stored in a health record system under the custody and control of the Ministry of Health. Where a Clinic Site is administered by a hospital, the hospital will collect, use and disclose your information as an agent of the Ministry of Health. You must consent to this to complete this form.

I have read and understood the above statement
 

You may be contacted by a hospital, local public health unit, or the Ministry of Health for purposes related to the COVID-19 vaccine (for example, to remind you of follow up appointments and to provide you with a record of immunization). You must consent to this to complete this form.

I consent to receiving follow-up communications by email or phone
 

Consent to being contacted about research studies

*You have the option of consenting to be contacted by researchers about participation in COVID19 vaccine related research studies. If you consent to be contacted, your personal health information will be used to determine which studies may be relevant to you, and your name and contact information will be disclosed to researchers. Consenting to be contacted about research studies does not mean you have consented to participate in the research itself. Participating in research is voluntary. You may refuse to consent to be contacted about research studies without impacting your eligibility to receive the COVID-19 vaccine. If you do not wish to be contacted about research studies, please indicate this below. If you consent to be contacted about research studies, and then change your mind, you may withdraw consent at any time by contacting the Ministry of Health at vaccine@ontario.ca. This will not impact your eligibility to receive the Covid-19 vaccine.

I consent to being contacted about COVID-19 vaccine related research studies by email or phone (If consenting for someone other than yourself, you confirm that you are the parent / legal guardian or substitute decision maker)
 
I confirm that I am a resident of Durham Region and have read and meet the criteria to complete this form.
 


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