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Request for French Interpretation Services Form (pdf/193.96 KB)
Please submit your form by email to NTHSSA_covidvaxrecords@gov.nt.ca.
Yellowknife Residents - Do not wait for notice by phone. 7 working days after submitting your form, please visit the YPCC location in person to receive your immunization records.
Request to Access COVID-19 Immunization Record (pdf/368.82 KB)
Medical Travel Expense Claim Form (pdf/669.79 KB)
Exception Request Form – Medical Travel (pdf/319.03 KB)
Adult FASD Diagnostic Clinic Referral Form (docx/260.32 KB)
Adult FASD Diagnostic Clinic Consent for Release (docx/162.25 KB)
Universal Fall Precautions (pdf/361.19 KB)
Consent for Dental Examination and Treatment Services - Grade 7 to12 (pdf/159.1 KB)
Consent to Fluoride Varnish - Well Child Program (pdf/128.27 KB)
Consent Form for Dental Examination and Prevention Services - JK to Grade 6 (pdf/150.21 KB)
Consent to Fluoride Varnish - JK and School Age Children (pdf/128.17 KB)
Self referral form for Physiotherapy (PT), Occupational Thereapy (OT), Audiology, and Speech Language Pathology (SLP).
Rehabilitation Services Self Referral Form (pdf/222.03 KB)
Service Fees Waiver Application (pdf/50.92 KB)