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Dose 2 Registration for Transplant Recipients and Cancer Patients

Dose 2 Registration for Transplant Recipients, Cancer Patients, and Dialysis Patients

Please note required fields are marked with an * Asterisk.

Format: L4M 6K9
Format: ###-###-####
YYYY-MM-DD , for example (1980-01-21)
(Enter numeric values only with no dashes or spaces. eg.9999999999)
If you don't have an Ontario Health Card Number please enter all zero's (i.e. 0000000000)
YYYY-MM-DD , for example (2021-04-06)
* Please Acknowledge
• Transplant recipients (including solid organ transplants and hematopoietic stem cell transplants)
• Individuals with malignant hematologic disorders and non-hematologic malignant solid tumors receiving stable, active treatment (chemotherapy, targeted therapies, immunotherapy), excluding those receiving solely hormonal therapy or radiation therapy
• I am a dialysis patient who has already received my first COVID-19 vaccination.
• Individuals who are taking an anti-CD20 agent (eg. rituximab, ocrelizumab, ofatumumab)
“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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