COVID-19 Immunization Form
This form is for Saskatchewan residents only to provide notification of a COVID-19 vaccination dose not entered in their
electronic record.
All fields are mandatory; however, you only need to provide information for the dose(s) that need to be updated in your
electronic record. Exception is if you have a COVID-19 immunization record and you are missing a lot number, click this box and
complete the Personal Information section:
IMPORTANT: Proof of Vaccination documentation (scanned document or photo) must be attached containing the following
information, which must be clearly visible: * Your First and Last Name * Date Vaccine Administered
* Vaccine Brand Received * Location Where Vaccine Received
NOTE: For In-Province vaccinations, please provide Saskatchewan wallet card.
Submit form with attached Proof of Vaccination documentation to the following email address:
MySaskHealthRecord@eHealthSask.ca
Contact information for eHealth Saskatchewan: Toll Free: 1-844-767-8259 (Canada and USA)
Missing Lot Number
Personal Information Required to Record Vaccination:
First Name: Last Name:
Date of Birth:
YYYY: DD: MM:
Saskatchewan Health
Services Number:
Gender:
Female Male Other
Address: City:
Postal Code: Phone:
Email Address:
Vaccination Information:
1st Vaccine Date:
YYYY: MM: DD:
1st Vaccine Brand:
1st Vaccine Location: City:Country:
2nd Vaccine Date:
YYYY: MM: DD:
2nd Vaccine Brand:
2nd Vaccine Location:
I hereby acknowledge the above information, including attached Proof of Vaccination documentation, is accurate and
subject to being audited for verification of the information provided.
Name:
(type or print name here)
* if applicable
Date:
August 3, 2021
In-Province Out of Province
Where was the Vaccination Administered?
In-Prov Site Name*
In-Prov Site Name*Country: City:
