Sign In
Our COVID-19 call centre is experiencing high call volumes and wait times may be long
. For more information, click here.
Contact
|
Hours
|
Location
Public Health is Everywhere!
Services
Dental
Dental
Fluoride
Free Dental Care
School Visits
Healthy Growth and Development
Healthy Growth and Development
Breastfeeding
Healthy Babies Healthy Children
Newborns
Nutrition
Parenting
Pregnancy
Safety
Babies and Toddlers
Healthy Living and Safety
Healthy Living and Safety
Active Living
Cancer Prevention
Climate Change
Cold, Heat, Air Quality and Sun Safety
Emergency Preparation
Environmental Health
Food Safety at Home
Healthy Aging
Healthy Eyes
Healthy Schools
Nutrition
Safety
Tobacco
Workplace
Youth
Harm Reduction and Substance Use
Harm Reduction and Substance Use
Alcohol
Cannabis
Harm Reduction Supplies Sites
Opioids
Safe Needle Disposal and Retrieval
Anti-Stigma
Immunization
Immunization
Vaccine Fact Sheets
View and Submit Immunizations
Flu Shot
Travel Clinic
Infectious Diseases
Infectious Diseases
Fact Sheets
Infection Prevention and Control Investigations
Rabies
Ticks and Lyme Disease
West Nile Virus
Coronavirus
Inspections
Inspections
Beaches
Food Safety
Personal Services Settings
Pests
Pool Safety
Tattoo Safety
Well Water Testing
Sexual Health
Sexual Health
Birth Control
Birth Control Fact Sheets
Sexually Transmitted Infections (STIs)
Clinics and Classes
Fluoride Varnish
Food Safety
Immunization
Immunization
School Clinics
Travel
Tuberculosis (TB) Skin Test
Parenting
Prenatal
Prenatal
Prenatal & Postnatal drop-in
Prenatal Classes
e-Learning
Quit Smoking
Sexual Health
Pool Safety
News
News Room
News Releases and Advisories
Statistics and Reports
Brant Health Atlas
Opioid Information
Reports
RRFSS Survey
About Us
About Us
Contact Us
Employment
Accessibility
Privacy
Terms of Use
Bid Opportunities
It looks like your browser does not have JavaScript enabled. Please turn on JavaScript and try again.
It looks like your browser does not have JavaScript enabled. Please turn on JavaScript and try again.
BCHU
School Vaccination Consent Form
Child Info
Vaccination History
Child Health
Consent
Confir
Step 1. Your child's information
Office Use Only
First Name:
Last Name:
Date of Birth:
Gender:
Male
Female
Other
Ontario Health Card #:
School:
select
E-Learning
In-Class
Parent/Guardian Name:
Daytime Phone:
Next >
Step 2. Your child's vaccination history
Please indicate if your child has previously received any of the following vaccines. If yes, please provide the dates of vaccination.
Meningococcal-ACYW-135 vaccine
Yes
No
(ex. Menactra, Menveo, or Nimenrix)
Please note this is NOT the same as the meningitis vaccination routinely administered at 1yr.
Date
Human papillomavirus (HPV) vaccine
Yes
No
(ex. Gardasil, Gardasil-9, or Cervarix)
Date of Dose 1
Date of Dose 2
Date of Dose 3
Hepatitis B vaccine
Yes
No
(ex. Twinrix, Twinrix Jr, Recombivax-HB, Engerix-B, or INFANRIX-hexa)
Date of Dose 1
Date of Dose 2
Date of Dose 3
< Previous
Next >
Step 3. Your child's health
Does your child have a weakened immune system due to illness or medication?
Yes
No
If yes, explain
Has your child ever had a reaction to a vaccine?
Yes
No
If yes, explain
Does your child have a history of fainting or seizures?
Yes
No
If yes, explain
Does your child have any allergies (e.g. yeast, alum, latex etc)?
Yes
No
If yes, explain
Does your child have a serious medical condition?
Yes
No
If yes, explain
< Previous
Next >
Step 4. Consent for vaccination
I have read the vaccine information sent by the Brant County Health Unit through my child’s school. I understand the expected benefits and possible risks and side effects of the vaccines. I understand the possible risks to my child if not vaccinated. I have had the opportunity to have my questions answered by the Brant County Health Unit. This consent is valid for one year. I understand that I can withdraw my consent at any time. I understand that my child may receive up to three needles in one day.
I give consent to the Brant County Health Unit to administer the following vaccines to my child:
(You must select “Yes” or “No” for each vaccine listed)
Meningococcal vaccine
Yes
No
Human papillomavirus (HPV) vaccine
Yes
No
Hepatitis B vaccine
Yes
No
Note: The Brant County Health Unit will review your child’s vaccination history (see Step 2) and vaccinate only if your child requires it.
I have read, understand and agree to the Brant County Health Unit’s
Privacy Statement
regarding the collection of information.
< Previous
Submit
Close
Confirmation message
Confirmation Message will pop-up here!
Close
Return to the Consent Form
