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Client NON-MRNA Vaccine Request Form

SMDHU has access to a very limited supply of non-mRNA vaccine and will be making it available to clients with a contraindication to mRNA vaccine or for those who do not want to receive an mRNA vaccine. Novavax and Janssen COVID-19 vaccines are available to those who do not want an mRNA vaccine. We do have to special order the vaccine and have to use the complete vials on the same day, so this will take some coordination and clients will be required to travel to a central location to receive the vaccine.

Please review the following prior to confirming your request:

Please complete the fields below:

Please note required fields are marked with an * Asterisk.

* I would like to be put on the list to receive this vaccine and understand I will be contacted by SMDHU if/when doses are available.
YYYY-MM-DD , for example (1980-01-21)
Enter numeric values only with no dashes or spaces (i.e.,9999999999)
If you don't have an Ontario Health Card Number please enter all zero's (i.e. 0000000000)

If you do not live in Simcoe County or the District of Muskoka, please follow up with your local Public Health Unit

* Please select the vaccine you would like to receive:

“The Health Unit collects personal information in the course of doing business. Personal information about you is collected directly from you or from the person acting on your behalf. Personal health information collected may include, for example, your name, date of birth, address, contact information, health card number, health history, and information you provide during visits or calls to the health unit.”

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If you have any questions or concerns that require a response, please contact Health Connection directly.

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