Page 58 - Covid-19 Vaccine Clinic
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Appendix Attached: Yes x No • Title: Ministry of Health, COVID-19 Vaccine Consent
Form – Pfizer-BioNTech COVID-19
7.0 DOCUMENTATION AND COMMUNICATION:
• Document at minimum that the immunization is given per COVID-19 Medical Directive and the
name and designation of the implementer.
• This medical directive will only be implemented if informed consent has been obtained from the
client.
• If the person does not provide consent the authorized implementer will not provide
immunization and document why consent was not obtained on the Ministry of Health COVID-19
Vaccine Consent Form (paper document) or electronically using the Ministry of Health database
known as COVax.
Appendix Attached: Yes No X Title: Appendix B:
8.0 REVIEW AND QUALITY MONITORING:
Medical directives are reviewed and approved by the Medical Advisory Committee every 2 years
or earlier, if a practice change is required.
9.0 ADMINISTRATIVE APPROVAL(S):
• Dr. Graham Berlyne, Chair, Corporate MAC
• Sonya Canzian, Executive Vice President, Clinical Programs and Chief Nursing and Health
Professions Officer
• Jennifer Bowman, Vice President, People and Transformation
• Cheryl Croutch, Director, Corporate Health, Safety and Wellness
10.0 APPROVING PHYSICIAN(S) / AUTHORIZER(S):
• Dr. Roohi Qureshi, Staff Physician, Occupational Health
• Dr. Graham Berlyne, Chair, Corporate MAC
11.0 REVIEWED BY:
• Professional Practice Executive Committee
12.0 AUTHOR(S) AND TITLE(S):
• Cheryl Croutch, Director, Corporate Health, Safety and Wellness
11.0 NEXT REVIEW DATE (2 YEARS):
• December, 2022
12.0 References and Resources:
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