This form is to identify people who provide direct client/patient care or a client from Phase 1 and Phase 2 of the vaccine roll-out who have not previously submitted an intake form and are interested in receiving a first dose of COVID-19 vaccination. If you do not meet this criteria, you will be eligible through the age-based roll-out, details at

Please note:

Your participation is voluntary and by completing this form, you are consenting to Island Health collecting and using your information for the purposes described below. Island Health will take all reasonable steps to ensure that your personal information is treated confidentially, and is kept secure as required by FIPPA.

The data collected will only be used for scheduling purposes in booking vaccination appointments.

Please complete the form only once, and ensure all fields are entered exactly as they appear on your Government issued identification (e.g. BC Services Card or Drivers License). Please note, if you received your first COVID 19 vaccine dose from an Island Health immunization clinic, Island Health will contact you for your second dose appointment and there is no need to complete this survey.

All appointments will be scheduled by order of the Provincial Priority list and are based on vaccine availability. Please note that it may take 2-4 weeks to be called after you submit the survey.

*Please ensure that you have read the medical considerations for vaccination prior to submitting your information*

Thank you!

Loading... Loading...
You have selected an option that triggers this survey to end right now. To save your responses and end the survey, click the button below to do so. If you have selected the wrong option by accident and do not wish to leave the survey, you may click the other button below to continue, which will also remove the value of the option you just selected to allow you to enter it again and continue the survey.
The response has now been removed for the last question for which you selected a value. You may now enter a new response for that question and continue the survey.