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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.
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BCHU
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COVID-19 Vaccine Booking Form
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Client Information
Client's First name
Client's Middle name
Client's Last name
Date Of Birth
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Gender
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Male
Female
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Ontario Health Card #
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Alternate ID type (if Health Card is not available)
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Birth Certificate
Employee ID
First Nation
Passport
MRN
Out of province Health Card #
Driver's license
Would you like to receive confirmation and reminder about your vaccine appointment?
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No
By selecting YES you are agreeing to BCHU to use your email and/or phone number to send you confirmation and reminders about your vaccination appointment as well as confirmation of appointment cancellation or rescheduling. The contact information provided will not be used for any other purpose.
Email
e.g. abc@xyz.com
Cell Phone
e.g. 000-000-0000
Home Phone
e.g. 000-000-0000
Please confirm if the following applies to you:
First Nation, Inuit and Métis individual or their non-Indigenous household member aged 18 and over?
Yes
No
Moderately or severely immunocompromised individual?
Yes
No
Please select dose(s) you want to book
First and second doses
First dose
Second dose
Third dose
Fourth dose
Book appointment for first dose
Date
No dates are available
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Time
No time slots are available
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Book appointment for second dose
Date
No dates are available
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Time
No time slots are available
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I have read, understand and agree to the Brant County Health Unit’s
Privacy Statement
regarding the collection of information.
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