Vaccine Accessibility Assessment Form

Complete this form to identify any accessibility needs during your vaccine appointment.

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

Date of appointment

Time of appointment

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

Provide details