COVID-19 Vaccine Injury Intake Form

Welcome to our intake form for members who are experiencing Vaccine Injury. At this point in time we are only treating adults, 18 yrs old and over. The intake process involves you providing CC TeleHealth with health details through which we can better understand your health challenges. As you know Vaccine Injury is a very complex health challenge. We believe CC TeleHealth provides a quality of treatment that is very rare. 

Vaccine Injury Treatment is Available in the Following Canadian Provinces:

  • Alberta
  • Ontario
  • Manitoba
  • Nova Scotia
  • Newfoundland & Labrador

Assessment Forms

The following forms will need to be completed, and will be used as part of your intake process:
  1. COVID-19 VACCINE INJURY INTAKE FORM: providing us with history of general health, COVID-19 history and Post Vaccine Injury;
  2. INFORMED CONSENT:  providing clarification of the science and practices we utilize, and your agreement to be treated based on our approach to science and developing treatment practices;
  3. COVID-19 VACCINE INJURY CONDITIONS ASSESSMENT TOOL: used for assessing the severity of health conditions you are experiencing;
  4. 2-DAY NUTRITIONAL TRACKING FORM:  Designed to track your diet and how it could be affecting your health.
* Please recognize that the more we know about you, the better we are able to help.