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?*

Yes

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?*

Yes

Note: Please enter your child's name as it appears on their health card.

First Name*

Middle Name

Last Name*

Address*

Address 2

City*

State/Province*

Zip/Postal Code*

Country

Email Address*

Phone*

Birthday*

Month Day Year

MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day01020304050607080910111213141516171819202122232425262728293031 Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923

Gender of child*

Female

Male

X

Parent or guardian name*

Parent or guardian phone number *

Parent or guardian relationship to child*

Mother

Father

Guardian

Please enter your child's Ontario Health Card number (10 numbers)*

Please enter the version code on your child's health card (2 letters)*

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

Date of first dose, if applicable

We are offering appointments on January 27, and February 10. If you have a preference in time, please state that below (between 2 p.m. and 4 p.m.) or (between 4 p.m. and 5:30 p.m.). If you have no preference, leave blank.