COVID-19 Immunization Record Update Request Form
First Name
*
Last Name
*
Date of Birth (YYYY-MM-DD)
*
Gender
*
Please select...
Female
Male
Other
Saskatchewan Health Services Number
I
do not have
a Saskatchewan Healthcare Number
Address
*
City
*
Postal Code
*
Phone
*
Email Address
*
Immunization events that need to be corrected
*
At least one Immunization Event and relative info: Brand, Vaccine Date, Cline/Pharmacy, City, and Country are required.
1.
Immunization Event
*
Please select...
Missing Dose
Missing Lot Number
Incorrect Date of immunization
Duplicate Entry
Out of Province
Not listed
Vaccine Brand
*
Please select...
Pfizer
Moderna
Astrazenica
Jansen
CanSinoBIO Ad5-n CoV
CoronaVac/SinoVac Inact Vero Cell
Covaxin Vero Cell
Covishield
SinoPharm Vero Cell
Sputnik Light rAD
Not Listed
Vaccine Date (YYYY-MM-DD)
*
Clinic/Pharmacy
*
City
*
Country
*
Comment
2.
Immunization Event
Please select...
Missing Dose
Missing Lot Number
Incorrect Date of immunization
Duplicate Entry
Out of Province
Not listed
Vaccine Brand
Please select...
Pfizer
Moderna
Astrazenica
Jansen
CanSinoBIO Ad5-n CoV
CoronaVac/SinoVac Inact Vero Cell
Covaxin Vero Cell
Covishield
SinoPharm Vero Cell
Sputnik Light rAD
Not Listed
Vaccine Date (YYYY-MM-DD)
Clinic/Pharmacy
City
Country
Comment
3.
Immunization Event
Please select...
Missing Dose
Missing Lot Number
Incorrect Date of immunization
Duplicate Entry
Out of Province
Not listed
Vaccine Brand
Please select...
Pfizer
Moderna
Astrazenica
Jansen
CanSinoBIO Ad5-n CoV
CoronaVac/SinoVac Inact Vero Cell
Covaxin Vero Cell
Covishield
SinoPharm Vero Cell
Sputnik Light rAD
Not Listed
Vaccine Date (YYYY-MM-DD)
Clinic/Pharmacy
City
Country
Comment
If 13 years of age or younger is applicable,
make my immunization visible
in MySaskHealthRecord.
Immunization Records Upload (DO NOT submit a QR code)
*
Required || Document type: .pdf, .jpg, .jpeg, .png, .gif || Maximum 5 files || Maximum upload size in total: 10MB