Community Clinic Immunization Consent

Consent to Collection, Use and Disclosure of Personal Health Information

York Region Public Health is collecting your personal health information for the purpose of providing immunization services to you/your child. The information you submit will be used for planning of vaccination clinics. The contact information you provide will be used if follow-up is required. Your personal health information is collected, used and disclosed for these purposes under the Health Protection and Promotion Act and in accordance with the Personal Health Information Protection Act, 2004. Please contact Access York at 1-877-464-9675 for questions regarding the collection, use and disclosure of this information.

Upon assessment by York Region Public Health nursing staff, vaccines eligible to be received by the student will be reviewed with the provider of consent. At that time, opportunity for questions will be provided, and the client and/or parent reserves the right to not consent to any or all of the vaccines. Consent provided is valid for two years from the date identified on this form.

I acknowledge the above to be true

I consent to receiving communication from York Region Public Health via text message to the phone number I have provided if follow up is required