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COVID-19 Related Vaccine Order Form

Please use this survey to request the vaccines once the approval has been granted by OPH.

For current processing times, please refer to our website Ottawa Public Health.

If you have any questions, please send an email to vaccine@ottawa.ca.

Please note that supplies are no longer available to order

Staff person designated to act as the contact for Ottawa Public Health for this vaccine event

Name:

Phone Number:

E-mail Address:

Please submit your monthly temperature log when placing a vaccine order.

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To minimize wastage of the vaccine while continuing to vaccinate all those who are eligible, please only order the amount of vaccine required to meet your needs.

Number of Doses: (Please indicate the number of doses being requested)

Authorized Organization Name (as found in Covax)

Authorized Organization Number (as found in Covax)

Your order will be delivered using your courier if you have one, otherwise we will contact you to pick up the vaccine.

Please enter clinic delivery handler/receiver contact information in the following fields:

E-mail:

Phone/Cell:

Comments:

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COVID-19 Related Vaccine Order Form

Staff person designated to act as the contact for Ottawa Public Health for this vaccine event

Your order will be delivered using your courier if you have one, otherwise we will contact you to pick up the vaccine.

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Reporting something to Ottawa Public Health or returning a message

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