Print a copy of the Third Party Immunization Form (PDF format). The cost of completing the Student Health Services Third Party Immunization Form is $50.00.
The cost of completion of third-party immunization forms is a service that is not covered by provincial or private health insurance plans. Student Health Services (SHS) processes multiple forms each day. In order to complete these requests effectively, we must adhere to the following policy.
- SHS has developed a generic, comprehensive Third Party Immunization Form that addresses all possible immunization requirements.
- Student Health Services will provide documentation for immunity status, vaccination history and TB screening using only this Third Party Immunization Form. The cost of completing this form is $50.
- To proceed with having an SHS Third Party Immunization Form and all accompanying tests and immunizations, contact the Student Health Services receptionist at 519-973-7002 to book this appointment with the Nurse. All immunization records and related third-party requests must be brought to the appointment.
- The Nurse will review the third party requests with the patient and order the necessary laboratory tests and required immunizations. TB skin tests will be completed and/or chest x-ray requisition will be given.
- OHIP covers the cost of TB tests for clinical placement.
- A fee is charged for TB testing needed for paid employment purposes.
- Cost: one-step $20; two-step $25 (if a patient has never had a TB test)
- The patient must schedule an appointment with a physician for two weeks after they have their blood work done. The Student Health Services' Physician will review and sign the SHS Third Party Immunization Form at this appointment.
- The cost of the Third Party Immunization Form is $50.00. Fees are payable at the first appointment. Debit/Visa and Mastercard are all acceptable forms of payment.
- SHS suggests that this process is started well in advance of form submission deadlines.
- Your patience is appreciated while we try to accommodate you in the timeliest manner possible.