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Quinte Health Care
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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?”*
We are currently booking vaccine clinic appointments for the highest and very high priority frontline staff and physicians at QHC hospitals.
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Note: Please enter your name as it appears on your health card.
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Gender*
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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.*