Revoke consent from program

Remove your registration from the vaccine incentive debit card program by completing the form below.

By submitting this form, you are stating that you do not consent to have your health information used to receive a $100 debit card and will no longer be eligible for the COVID-19 Vaccine Incentive Program. This action cannot be undone.

This form cannot be used to register to receive the Vaccine Incentive Debit Card.

All fields are required unless otherwise indicated.

Collection notice

This information is collected so that we can update your registration.

The personal information is being collected and used pursuant to section 33(c) and section 39(1)(a) of the Freedom of Information and Protection of Privacy (FOIP).

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