COVID-19 VACCINE CLINIC - INVITATION ONLY

 

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 (by invitation only).

Complete all required fields in the form. This form must be completed separately for each person 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 Registration Status for your COVID-19 Vaccination Clinic visit?*

Yes

Note: Please enter your name as it appears on your 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*

Female

Male

X

Place of employment*

Job title

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.*

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

We are offering appointments 9am-5pm on Friday, January 14 and Thursday, January 20.