Vaccine Accessibility Assessment Form

Required fields are marked with asterisks (*)

Version française

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

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

Appointment details

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

Vaccination location

Accommodations

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

Please select any accommodations required at the vaccination appointment
 


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