I have read and understood the fact sheet(s) regarding the risks and benefits of the vaccine that I am consenting be administered to the above named person as per section A. My consent applies to all doses of the vaccine necessary to complete the series up to one year. I have had the opportunity to ask questions about the vaccine(s) which were answered to my satisfaction

Notice: Information about the immunizations you or your dependent(s) receive may be recorded in the provincial immunization registry. This registry allows your health care providers to find out what immunizations you or your dependent(s) have had or need to have. Information collected in the provincial immunization registry may be used to produce immunization records, or notify you or your doctor if a particular immunization has been missed. Manitoba Health and Seniors Care may use the information to monitor how well different vaccines work in preventing disease. The Personal Health Information Act protects your information. You can have your personal health information hidden from view from health care providers. For more information, please contact your local public health office to speak with a public health nurse www.manitoba.ca/health/publichealth/offices.html.