Lambton Public Health – Your Community, Your Health

This consent form is to be completed for all students entering Grade 7 in September, indicating either a yes or no response for each of the three immunizations offered.

Student Information

First Name*

Last Name*

Ontario Health Card #*

Only enter the 10 numbers from your Health Card. If you do not have a Health Card, enter 1111.

School*

Date of Birth*

Address

Street Address City Province / Territory Postal Code Country

Grade*

Parent/Legal Guardian Information

Parent/Legal Guardian First Name*

Parent/Legal Guardian Last Name*

Relationship to Student*

Primary Phone*

Secondary Phone (optional)

Consent for Immunization

I have read the related vaccine information sheet. I understand the expected benefits and possible risks and side-effects of the vaccines. I understand the possible risks to my child if not vaccinated. I had the opportunity to have my questions answered by Lambton Public Health. This consent is valid for two (2) years. I understand that I can withdraw my consent at any time. I understand that my child may receive up to three (3) needles in one day.

Meningococcal ACYW-135
_{*Required for school attendance}

I authorize Lambton Public Health to administer 1 dose of meningococcal ACYW-135 vaccine to my child.*

Yes

Hepatitis B

I authorize Lambton Public Health to administer 2 doses of hepatitis B vaccine to my child.*

Yes

Human Papillomavirus (HPV)

I authorize Lambton Public Health to administer 2 doses of human papillomavirus (HPV) vaccine to my child.*

Yes

If your child has been previously immunized with any of the vaccines mentioned, please update or view your child’s immunization record online at LambtonPublicHealth.ca/reporting-immunizations. If you need assistance, contact us by email at immunization@county-lambton.on.ca or call 519-383-8331.

Student Health History

Is your child allergic to yeast, aluminum, latex, diphtheria toxoid protein, other?*

Yes

Additional Details about your Child's Allergies*

Has your child ever had a reaction to a vaccine?*

Yes

Additional Details about any serious reaction to vaccination that your child has experienced*

Does your child have a history of fainting or seizures?*

Yes

Additional Details about your child's history of fainting or seizures*

Does your child have any medical condition(s)?*

Yes

Additional Details about any medical conditions or diagnosis that your child may be experiencing*

Does your child have a weak immune system or is your child taking a medication that increases the risk of infection? (e.g. corticosteroids)*

Yes

** We recommend that you visit your health care provider or specialist to receive these vaccines at the appropriate schedule. If your provider cannot administer these vaccines, we require a schedule from your child’s health care provider prior to immunizing your child at school. Please contact us at 519-383-8331 to provide this schedule for approval by our Medical Officer of Health. **

Additional Details about any illnesses or medications that could weaken your child's immune system*

Does your child require accommodations?*

Yes

Additional Details about your child's accommodation needs*

Acknowledgements

Consent to Collection, Use and Disclosure of Personal Health Information: Lambton Public Health is collecting your personal health information for the purpose of providing immunization services to your child. The information you submit will be used for planning of vaccination clinics. The contact information you provide will be used if follow-up is required. Your personal health information is collected, used and disclosed for these purposes under the Health Protection and Promotion Act and in accordance with the Personal Health Information Protection Act, 2004.

Acknowledged On 11/21/2024

Acknowledgement*

I acknowledge the above to be true

Consent to Receive E-mail Confirmation

By providing your email address you are consenting to receive an email from Lambton Public Health confirming receipt of this consent form. Please understand if emailing personal health information that email software and/or services are not guaranteed to be completely secure, and although all precautions possible are taken by Lambton Public Health, emailed information could be inappropriately accessed by others.

Personal health information on this form is collected under the authority of the Health Protection and Promotion Act, R.S.O. 1990, c.h.7. Information is used to administer the Lambton Public Health Vaccine Preventable Diseases Program, including maintaining immunization records for students. If you have any questions about the collection and maintenance of this information, call Lambton Public Health at 519-383-8331 or toll-free 1-800-667-1839.

For more information contact Lambton Public Health at 519-383-8331