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Acknowledgement of Collection, Use and Disclosure of Personal Health Information

The personal health information on this form is being collected for the purpose of providing care to you and creating an immunization record for you, and because it is necessary for the administration of the private COVID-19 vaccination program. This information will be used and disclosed for these purposes, as well as other purposes authorized and required by law. For example,

– it may be disclosed, as part of your provincial electronic health record, to health care providers who are providing care to you.

The information will be stored in a health record system under the custody and control of the Ministry of Health.

1معلومات شخصية / Personal Information
2عنوان السكن / Home Address
3معلومات للتواصل / Contact Details
4معلومات صحية / Medical information
  • سيتم مقارنتها بوثائق رسمية (بنسختها الأصلية) خلال عملية التلقيح وأتحمل المسؤولية الكاملة /
    It will be cross-checked with the official documentation (in its original version) during the vaccination process and I assume full responsibility.

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