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COVID-19 Vaccine Clinic for Quinte Children's

Treatment Centre Clients - Ages 5 to 11

 

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 register for the COVID-19 Vaccination Clinic at Quinte Health Care Belleville General Hospital (Quinte Children's Treatment Centre clients, ages 5-11, only).

Complete all required fields in the form. This form must be completed separately for each child requiring a COVID-19 vaccination appointment.  Within 24-48 hours you will be provided with instructions and directions for attending the clinic.  

Quinte Health Care has made an exception to allow the use of unencrypted email for the purpose of registering for vaccination during the pandemic.  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 Reregistration Status for your child's COVID-19 Vaccination Clinic visit?*
Do you confirm that the child you a registering for COVID-19 vaccination is a client of the Quinte Children's Treatment Centre and meets the age criteria of 5-11 years old?*
Note: Please enter your child's name as it appears on their health card.
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Birthday*
  
Gender of child*
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Parent or guardian relationship to child*
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