WELCOME TO TOTAL HEALTH PHARMACY IN OAKVILLE

We offer dispensing of prescription medication, over the counter medications, vitamins, supplements and advice. Visit us today at 1131 Nottinghill Gate in Oakville!

At Total Health Pharmacy, we take care of your total health. Using the latest innovations, we are able to better serve customers, ensuring they receive the medications they need coupled with the proper instructions.

COVID Vaccine Screening Form

Please fill out and submit this form before coming for your influenza vaccine appointment.

First Name

Last Name

Gender

Date of Birth

Weight

Address

Phone Number

Emergency Contact

Relationship to Patient

Contact's Phone Number

Contact's 2nd Phone Number

The following questions will help us determine if there is any reason you or your child should not get the vaccine today.
If you answer "yes" to any question, it does not necessarily mean the shot cannot be given.
It simply means additional questions must be asked.

If a question is not clear, please ask your pharmacist to explain it.

Have you had a COVID vaccine? If so, which one did you receive and when did you receive it?

Detail:

Have you experienced major venous and/or arterial thrombosis with thrombocytopenia following vaccination with any vaccine? (This question is for patients receiving a viral vector based COVID vaccine.)

Have you experienced a previous cerebral venous sinus thrombosis (CVST) with thrombocytopenia or a heparin-induced thrombocytopenia (HIT)? (This question is for patients receiving a viral vector based COVID vaccine.)

Are you experiencing any cold, flu or COVID-19-like symptoms, even mild ones?

Have you travelled to any countries outside Canada (including the United States) within the last 14 days?

Did you provide care or have close contact with a person with confirmed COVID-19?

Have you received a flu vaccine or any vaccine in the past 14 days?

Do you have a new or changing neurological disorder?

Have you had a serious reaction to a vaccine in the past?

Have you ever had a serious reaction to polyethylene glycol (applicable to mRNA based vaccines only)?

Have you ever had Guillain-Barre Syndrome within 6 weeks after receiving a vaccine? (A Yes answer is not a contraindication for mRNA based vaccines).

Are you pregnant and/or breastfeeding?

Are you currently taking any medication?

Do you take a blood thinner or have a bleeding disorder?

Do you have an autoimmune disorder or weakened immunity due to illness/treatment?

Are you allergic to latex gloves?

Do you have a history of chronic illness?

Do you have a history of fainting?

Have you ever had a COVID-19 infection/positive test?

Have you had a condition known as MIS-C (Multisystem Inflammatory Syndrome-applicable if patient is a child)?

Have you received monoclonal antibody or convalescent plasma treatment?

Are you scheduled for Tuberculin Skin Testing (TST) or interferon gamma release assay (IGRA) test in the next 4 weeks?

I, the undersigned patient/guardian/agent, have read or had explained to me information about the COVID shot as outlined on the Fact Sheet. I have had a chance to ask questions, and answers were given to my satisfaction. I understand the risks and benefits of receiving the COVID shot. I agree to wait/have my child wait/have the client wait in the pharmacy for 15 minutes (or time recommended by the pharmacist) after getting the COVID shot. I am aware that it is possible (yet rare) to have an extreme allergic reaction to any component of the vaccine. Some serious reactions called "anaphylaxis" can be life-threatening and is a medical emergency. If I/my child/my client experience such a reaction following vaccination, I am aware that it may require the administration of epinephrine, diphenhydramine, beta-agonists, and/or antihistamines to try to treat this reaction and that 9-1-1 will be called to provide additional assistance to the immunizer. The symptoms of an anaphylactic reaction may include hives, difficulty breathing, swelling of the tongue, throat, and/or lips. In the event of anaphylaxis, a copy of this form containing information on emergency treatments received will be provided to you, your guardian, your agent or EMS paramedics.

I confirm that I want to receive the COVID vaccine I confirm that I have legal authority to this immunization

If your child is less than 9 years of age, and getting the influenza vaccine for the first time, your child will need 2 doses of vaccine this season. They are given at least 4 weeks apart.

Full Name

Date of Submission

Thank you for submitting your form. We will contact you to book an appointment once the vaccine becomes available

Our Guidelines to Protect Against COVID-19

To promote SOCIAL DISTANCING:

1. When waiting for your prescription(s)

You can wait outside in your car (we can call/text when ready)
If you are waiting in the store, please try to keep a 2-metre distancing from others
Have your physician fax us your prescription directly or email it to us ahead of time and bring in the original at the time of pick up

2. Refills

Call ahead or try our online system
Give us 1 week notice in order to ensure that we have time to deal with any stock issue or having to contact your doctor
Take advantage of our free delivery

3. Consultations

Consider calling instead of face-to-face
Feel free to submit questions by email or by using our refill website

Send In Your Online Refill Request By Clicking Here

If you leave us a phone message, we WILL get back to you. If you are placed on hold, consider asking the staff to take your name and number and we will call you back when we are more available. We appreciate your patience during this challenging time!

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