Form Builder

Required fields are marked with asterisks (*)

Community Partner COVax Onboarding Request Form

Please fill out the below form to provide necessary information about your planned vaccination clinic(s) under Ottawa Public Health’s authorized organization. Please DO NOT share any sensitive, personal and/or client information in this form.

Thank you.

Primary Contact Information

City of Ottawa/Ottawa Public Health Contact

If you have already been in contact with a City of Ottawa/Ottawa Public Health staff member, please include their name here. If not, please leave this section blank.

Do you have an agreement in place with Ottawa Public Health?
 

Vaccination Event

Please provide the name and address of the location where you plan to administer vaccines.

Vaccine delivery model
 


Contact Us