Interior Health - Immunizer Form
***** Warning! *****
JavaScript is off. This requires JavaScript to function properly. Please enable to view full site.
Click here for instructions how to enable JavaScript in your web browser
This form is intended for health-care professionals interested in helping with immunizations at one or more of Interior Health’s COVID-19 Immunization Clinics. Expressing an interest does not automatically commit you to the program. You will be contacted by a Public Health representative in the coming weeks to discuss your availability.
Personal Demographics
First Name
*
Last Name
*
Town/City
*
Please provide one or more of the following phone numbers:
*
Home Phone
Cell Phone
Other Phone
Other Phone Belongs To
*
Preferred Contact Number
*
Please select
Home
Cell
Other
E-mail
Availability and Experience
What communities are you willing to help immunize in? Please list the name of each town or city:
*
I am available on the following days:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
I am available starting from
*
I am available until
*
To help us understand your experience and determine where you will be the most help, please select from one of the following options:
*
I am currently a practising nurse/physician/pharmacist or other health-care professional with experience in immunizations.
I am a retired (non-practising) nurse/physician/pharmacist or other health-care professional with experience in immunizations.
I have no clinical health-care experience.
Regardless of the option selected above, you will be contacted by a Public Health representative who will provide or obtain additional information.
Profession
*
Please select
Midwife
Anesthesiology Assistant
Dental Hygienist
Dentist
First Responder
Non-Clinical
Non-Practicing Physician
Nursing Student
Paramedic
Pharmacist
Practicing Physician
Registered/Licensed Nurse (RN/LPN/RPN)
Unregistered Nurse
Other
Applicable License number
Comments:
Please check each statement to acknowledge you have read our site policies, and then click submit form to Interior Health
*
I have read and fully understand this notification with regards to the collection, storage, and use of my personal information
(click here to review)
I,
certify the information I provided on and in connection with this form is true and correct to the best of my knowledge.
Please leave this field empty
***** Warning! *****
JavaScript is off. This requires JavaScript to function properly. Please enable to view full site.
Click here for instructions how to enable JavaScript in your web browser
Increase Text
Decrease Text
