Fourth dose appointment booking is available for those aged 60+ as well as First Nation, Inuit and Métis individuals and their non-Indigenous household members aged 18+. Please visit our COVID-19 vaccine page for info on eligibility and appt., booking. For more information, click here.

Contact|
Hours|
Location

Public Health is Everywhere!

Services
- Dental
- Healthy Growth and Development
- Healthy Living and Safety
- Harm Reduction and Substance Use
- Immunization
- Infectious Diseases
- Inspections
- Sexual Health
Clinics and Classes
News
Statistics and Reports
About Us

BCHU

Body

School Vaccination Consent Form

Child Info
Vaccination History
Child Health
Consent
Confirmation

Office Use Only

Step 1. Your child's information

Client's First name

Client's Last name

Date Of Birth (mm/dd/yyyy)

Gender

Ontario Health Card #

e.g..0000-000-000-XX

School

Grade

Parent/Guardian Name

Daytime Phone

e.g. 000-000-0000

Step 2. Your child's vaccination history

Please indicate if your child has previously received any of the following vaccines.

Meningococcal-ACYW-135 vaccine

Yes

(ex. Menactra, Menveo, or Nimenrix)

Please note this is NOT the same as the meningitis vaccination routinely administered at 1yr.

Date of Dose 1: (mm/dd/yyyy)

Human papillomavirus (HPV) vaccine

Yes

(ex. Gardasil, Gardasil-9, or Cervarix)

Date of Dose 1: (mm/dd/yyyy)

Date of Dose 2: (mm/dd/yyyy)

Date of Dose 3: (mm/dd/yyyy)

Hepatitis B vaccine

Yes

(ex. Twinrix, Twinrix Jr, Recombivax-HB, Engerix-B, or INFANRIX-hexa)

Date of Dose 1: (mm/dd/yyyy)

Date of Dose 2: (mm/dd/yyyy)

Date of Dose 3: (mm/dd/yyyy)

Step 3. Your child's health

Does your child have a weakened immune system due to illness or medication?

Yes

If yes, explain

Has your child ever had a reaction to a vaccine?

Yes

If yes, explain

Does your child have a history of fainting or seizures?

Yes

If yes, explain

Does your child have any allergies (e.g. yeast, alum, latex etc)?

Yes

If yes, explain

Does your child have a serious medical condition?

Yes

If yes, explain

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. 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

Human papillomavirus (HPV) vaccine

Yes

Hepatitis B vaccine

Yes

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.

Confirmation message

Confirmation Message will pop-up here!

Quick Links

School Health
Healthcare Providers
Inspection Services
Board of Health
Contact Us
Employment
View and Submit Immunizations
School Vaccination Consent Form

Services

Dental Health
Family Health
Healthy Living and Safety
Harm Reduction and Substance Use
Immunization
Infectious Diseases
Inspections
Sexual Health

194 Terrace Hill St.,
Brantford, ON
N3R 1G7
Tel: 519-753-4937
Fax: 519-753-5942

Privacy
Terms of Use
Accessibility
Employee Services