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COVID-19 Vaccine Accessibility Assessment

Complete this form to indentify any accessibility needs during your COVID-19 vaccine appointment.

For more information about the accessibility supports available at all sites visit our clinic FAQ page.

If you have difficulty completing this form please call 613-691-5505.

Are you completing this form for yourself or on behalf of someone else?

Completing for myself

Completing on behalf of someone else

Appointment details

Note: some requests may need a minimum of 48 hours to accommodate supports required

Vaccination location

Date of appointment

Time of appointment

Note: Some requests may need a minimum of 48 hours to accommodate supports required

Provide details