COVID-19 Vaccine Benefit/Risk Form for Individuals Requesting to Receive Additional (Third and/or Fourth) Doses To enable international travel to countries, agencies (e.g., cruise ship lines) and venues that do not approve of select COVID-19 vaccine series, certain individuals are eligible to receive additional doses of COVID-19 vaccines. Please refer to Table 1 on the back of this page for recommendations. The National Advisory Committee on Immunization (NACI) and the Public Health Agency of Canada (PHAC) do not have recommendations to guide Canadian provinces and territories on the administration of a third COVID-19 vaccine dose to individuals who previously received two valid COVID-19 vaccine doses as a mixed vaccine series. All COVID-19 vaccines licensed by Health Canada are safe and effective, and offer good protection against strains of the virus including the Delta variant. There is preliminary information on the safety of third COVID-19 doses. It is expected that individuals may experience mild to moderate symptoms (e.g., fever, chills, aches, and pain at the injection site) after third and fourth doses. I understand that my third or fourth dose must be received at least 28 days following the most recent COVID-19 immunization. Additional intervals from other vaccine may apply. I have read and been fully informed by the health care provider regarding the above information. I hereby give permission for myself or my child to receive an additional COVID-19 vaccine dose as indicated below. Pfizer dose # _____ Moderna dose # ______ AstraZeneca dose # _____ (Only available at Public Health; not available in pharmacies) _______________________________ _______________________________ Client Name HSN __________________________________ ___________________________ Client or Parental/Guardian Signature Date ___________________________________ ___________________________ Immunization Provider and Designation Date saskatchewan.ca/COVID-19 Table 1: Third and Fourth COVID-19 Dose Recommendations Dose 1 Dose 2 Dose 3 Dose 4 COVISHIELD COVISHIELD Pfizer Pfizer COVISHIELD COVISHIELD Moderna Moderna COVISHIELD AstraZeneca Pfizer Pfizer COVISHIELD AstraZeneca Moderna Moderna AstraZeneca AstraZeneca Pfizer Pfizer AstraZeneca AstraZeneca Moderna Moderna AstraZeneca COVISHIELD Pfizer Pfizer AstraZeneca COVISHIELD Moderna Moderna COVISHIELD Pfizer Pfizer COVISHIELD Moderna Moderna AstraZeneca Pfizer Pfizer AstraZeneca Moderna Moderna Pfizer Moderna Moderna Pfizer Moderna Pfizer Moderna Pfizer Pfizer Moderna Pfizer Moderna Pfizer AstraZeneca Pfizer Pfizer COVISHIELD Pfizer Moderna AstraZeneca Moderna Moderna COVIDSEHILD Moderna Note: AstraZeneca may be given to individuals who have contraindications to mRNA vaccines. August 17, 2021 2 COVID-19 Vaccine Benefits and Risk Form
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