Please note: this webform works best using an updated browser other than Internet Explorer, such as Google Chrome or Microsoft Edge. 

This webform is for use to pre-register for the COVID-19 Vaccination Clinic at Quinte Health Care Belleville General Hospital. 

Complete all required fields in the form. This form must be completed separately for each person requiring a COVID-19 vaccination appointment.  Within 24 hours you will be provided with instructions and directions for attending the clinic.  

Your second dose of COVID-19 vaccine will also be booked for you when you submit this form (scheduled for 35 to 42 days after your first dose). 

Quinte Health Care has made an exception to allow the use of unencrypted email for the purpose of preregistering during the declared emergency.  In order for QHC to use unencrypted email, we must obtain the consent of the patient for this purpose.    

Do you consent, understanding that unencrypted email carries an inherent risk of disclosure to third parties, to the use of email for the purpose of sending confirmation of your Preregistration Status for your COVID-19 Vaccination Clinic visit?”*

Yes

We are currently booking vaccine clinic appointments for the highest and very high priority frontline staff and physicians at QHC hospitals.

What is your role at QHC and unit? E.g. RN, ICU*

Please enter your Ontario Health Card number. If you don't have a health card, please explain (e.g. military, out of country, other).*

Please enter the version code on your health card number. If you don't have a health card, enter n/a. *

First Name*

Note: Please enter your name as it appears on your health card.

Middle name. (As it appears on health card) *

Last Name*

Address*

Address 2

City*

State/Province*

Zip/Postal Code*

Country

Email Address*

Please use your work email address (i.e. your QHC email address, or the email address from which you received a link to this registration form).

Phone*

Birthday*

Month Day Year

MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day01020304050607080910111213141516171819202122232425262728293031 Year20212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921

Gender*

Female

Male

X

Marital Status*

Family Doctor (include first and last name). Enter n/a if you don't have a family physician.*

Please enter the name of an emergency contact or next of kin. *

Please enter the contact phone number for your emergency contact or next of kin. *

What is your relationship with the emergency contact or next of kin? *

What are your preferred dates for a vaccination appointment? Please choose 3 potential dates and indicate for each of these dates which timeframe would be preferable. The timeframe options are 1:30 p.m. – 5 p.m. (option #1) or 5:30 p.m. to 8:30 p.m. (option #2). For example, (March 8, option #1; March 11, option #2; March 12, option #2). Please note when picking your dates that the vaccine clinic is running Monday-Friday (while vaccine supplies last). *UPDATE – we are now booking from March 8th onwards.*

Your second dose of COVID-19 vaccine will also be booked for you when you submit this form (scheduled for 35 to 42 days after your first dose).

By checking this box, I certify that I am part of the Highest Priority or Very High Priority health care worker vaccination prioritization groups. I do not believe that I am booking my vaccination out-of-turn according to QHC's health care worker prioritization plan.*

Yes