If you receive one dose of the Moderna COVID-19 Vaccine, you should receive a second dose of the same vaccine 1 month later to complete the vaccination series. By signing this consent you (agree for your child to receive both doses of the vaccine). Yes No Was the severe allergic reaction after receiving another vaccine or injectable medication? This vaccine has not undergone the same type of review as an FDA-approved or cleared product. The Moderna COVID-19 Vaccine is administered as a 2-dose series, 1 month apart, into the muscle. Please keep your appointment or call if you need to cancel or change it. CONSENT FOR VACCINATION I will/have reviewed my answers to … I understand that I should remain in the vaccine administration area Download the agreement. This information will help keep track of the manufacturer and . COVID-19 Vaccine Consent Form CONSENT FORM – Pfizer-BioNTech COVID-19 Vaccine Version 1.1 – December 14, 2020 Last Name First Name Identification (e.g., health card number) Home Phone Mobile Phone Email Address Primary Care Clinician (Family Physician or Nurse Practitioner) Street Address City Province Postal Code Date of Birth ☐ Section 1: Information about Person to Receive Vaccine (please print, sign and bring with you to your appointment in order to be vaccinated) PATIENT NAME (Last) (First) (M.I.) I have read, had explained to me, and understand the information in the EUA. All recipients of the vaccine must sign the COVID-19 vaccination consent form, before they can be vaccinated at the hospital / clinic. • A vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction. Moderna’s COVID-19 Vaccine Consent Form (English / Spanish) Johnson & Johnson's Janssen COVID-19 Fact Sheet for Healthcare Providers Administering Vaccine (FDA EUA Letter) Johnson & Johnson's Janssen COVID-19 Vaccine Consent Form (English / Spanish) COVID-19 Vaccines Pre-vaccination Screening Forms (English / Spanish) We appreciate you getting the COVID-19 vaccine as it is important to our community. care provider. The Moderna COVID-19 Vaccine will be given to you as an injection into the muscle. CHHD and VHwill return to the school in 3 weeks to provide the second dose of vaccine. This vaccine is not FDA-approved. Sunday May 23, 2021 – 9 am – 4 pm. I have been provided with and have read the EUA Fact Sheet for the COVID-19 vaccine, the COVID-19 Vaccine Consent Form, and any additional information provided. IMPORTANTLY, you still need to register the same way to provide consent, select a vaccine, etc. Patient Information . COVID Vaccine Consent Form * Please fill out the required details below If you have remaining questions, please call us at (229) 262-6173. child named at the top of this form to be vaccinated with I understand that this is a two dose series andthis vaccine. Clothing that will allow unrestricted access to your shoulder and upper arm to administer your COVID-19 vaccine; Insurance is NOT required to get a vaccine and there will be no charges or copays to the vaccine recipient. I also acknowledge that I have had a chance to ask questions and that such questions were answered to mysatisfacti on. In the event of an accidental post vaccination needle stick to the vaccine administrator, I agree to be contacted for follow up lab work. This vaccine is not FDA-approved. The Moderna COVID-19 Vaccine is an unapproved vaccine that may prevent COVID-19. Patient Information . The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. COVID-19 Vaccination Clinic. COVID-19 Vaccine Parental Consent Form . It is your choice to receive the Moderna COVID-19 Vaccine. I understand that the COVID - 19 vaccine requires t wo (2) doses to confer immunity and if I do not complete the full series then I will not receive the full benefit of the vaccine. Date of Birth . The Moderna COVID-19 Vaccine is an unapproved vaccine that may prevent COVID-19. To access the COVID-19 Vaccine Agreement, simply fill out the form below and click the download button. COVID-19 Vaccine Consent Form WHAT TO DO IF YOU HAVE A REACTION TO THE COVID-19 VACCINATION Most people have side effects from the vaccination, but these usually only last 24 – 48 hours after receipt of the vaccination. Information Sheet for this vaccine which explains the purpose, side effects, and possible complications of this vaccine and that after review of such documents, I consent to the administration of the COVID-19 Vaccine. Patients reporting a serious reaction to a previous dose of COVID-19 vaccine, any vaccine, or injectable therapy (intramuscular, intravenous, or subcutaneous), should be asked to describe their symptoms. (individual’s name) I understand by declining the administration of the COVID-19 vaccine at this time, I have the ability to change this decision in the future and will be required to complete a new consent form in order for such change to be determined valid. I know that the person named below will have the COVID-19 vaccine injected into their body to prevent the COVID-19 disease that the COVID-19 vaccine is meant to prevent. Consent form for COVID-19 vaccination About COVID-19 vaccination People who have a COVID-19 vaccination have a much lower chance of getting sick from the disease called COVID-19. COVID-19 Vaccine Consent Form ... Moderna COVID-19 Vaccine, which you may receive because there is currently a pandemic of COVID-19. On this page: Adverse Events Following Immunization COVID-19 Immunization Documents Provincial Guidance Infection Prevention and Control Health Canada National Advisory Committee on Immunization Public Health Agency of Canada Vaccine Product Information Pharmacist Guidance *new* Physician Guidance *new* Adverse Events Following Immunization All Adverse Events Following Immunization … I understand the FDA has authorized the You no longer have to pick a time. Delivery of Consent Form CONSENT FORM –COVID-19 Vaccine . Page 1 of 2 Moderna COVID-19 Vaccine Effective Date: 1/04/2021 COVID-19 VACCINE SCREENING AND CONSENT FORM Moderna COVID-19 Vaccine SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT) Name: Last: First: Middle Initial: Date of Birth: Month Day Year Mobile Phone Number (Patient or Guardian): ( ) Address: Apt/Room #: I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including Consent to Receive the Vaccine I have read (or it has been read to me) and I understand the Immunization Prepackage, including the following documents: ‘COVID -19 Vaccine Information Sheet’ or the ‘ COVID-19 Vaccine Information Sheet: For Youth (age 12 -17)’ and ‘What youth need to know about their COVID -19 vaccine appointment’. Patient Signature _____ Date _____ In order to have the Covid-19 vaccine administered (“the Covid-19 vaccine”) you must provide Upson Regional Medical Center’s COVID-19 Vaccine Consent Form 2 Updated 2/15/2021 Section 3: Screening Questions The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. I authorize Sutter Valley or Sutter Bay Medical Foundation to provide the Minor Patient with medical care and treatment in my absence. ... Our Knowledgeable pharmacy teams are staying up to date on the latest COVID-19 vaccine developments & recommendations. Most people will experience pain, redness and/or soreness at the injection site. Ministry of Health COVID-19 Vaccine Consent Form CONSENT FORM –COVID-19 Vaccine … Birth registrars: DO NOT use this form. Consent Form. 12.07.2020 COVID-19 Vaccine Consent & Release Authorization (PLEASE PRINT) Patient Last Name: First Name: MI: Sex: ☐ M ☐ F DOB:/ Age Address: City: State: Zip: Cell Phone: ( ) Alternate Phone: ( ) The following questions will help determine if there is any reason you should not receive a COVID Last Name First Name Date of Birth Gender. the person for whom I am authorized to consent) have received this COVID-19 vaccine. Personal Information circle . ***** Signature and Title of Vaccine Administrator:_____ doses of the vaccine. A parent or guardian should complete the consent form for youths under 18. If No If Yes – allow to schedule –“Defer vaccination until improvement in symptoms for 19 vaccine. Age in Years Sex (Gender assigned at birth) Month Day Year Male Female Effective Date: 3/25/2021 COVID-19 Second Dose Vaccine Consent SECOND DOSE COVID-19 VACCINE CONSENT AND ACKNOWLEDGEMENT FORM Name: Last: First: Middle Initial: Date of Birth: Month Day Year Social Security Number: … Personal Information. Lines have dissipated too, becoming more light and variable. For more information about COVID-19 in Alabama, visit Coronavirus Disease 2019 (COVID-19). VACCINATION CONSENT FORM Moderna COVID-19 Vaccine The novel coronarvirus SARS-CoV-2 (a/k/a COVID-19) is an infectious disease that appeared in late 2019. If you do not have an email or would prefer to give information over the phone, please call the pharmacy at (636) 239-4707. A COVID-19 vaccine declination form is a consent collection document used for the purpose of getting a patient or a person's express intention to decline from receiving vaccination from COVID-19. child named at the top of this form to be vaccinated with I understand that this is a two dose series andthis vaccine. COVID-19 Vaccine Consent Form 3 Updated 12/27/2020 Section 5: Consent I have received (electronically or in hard copy) and read the FACT SHEET, or have had explained to me, the information in the FACT SHEET for the COVID-19 Vaccine and this COVID-19 Vaccine Consent Form. By signing the consent, I acknowledge that I understand the following: The FDA has authorized the emergency use of the Johnson & Johnson COVID-19 Vaccine that may prevent COVID-19. influenza vaccine, or (iv) the parent or legal guardian of the minor patient requesting immunization with the COVID-19 vaccine, or (v) the legal guardian of the patient. If you consent to be contacted about research studies, and then change your mind, you may withdraw your consent at any time by c ontacting the Ministry of Health at. Informed Consent: I answered all the questions correctly to the best of my knowledge. CONSENT . Written or signed consent is not required by the FDA or CDC for COVID-19 vaccination. I have had a chance to ask questions, which were answered to my satisfaction. This COVID-19 Vaccination Consent Form is for Schroder Drugs in Washington, MO location. Vaccine@ontario.ca. Read this Fact Sheet for information about the Moderna COVID-19 Vaccine. Read this Fact Sheet for information about the Moderna COVID-19 Vaccine. COVID-19 vaccine is given, and the risks associated with the COVID-19 vaccine. However, if a state law require s written consent for vaccinations , IHS … 02/2021) Use this form to register your child, aged 17 and younger, in ImmTrac2. Change the template with exclusive fillable fields. The Moderna COVID-19 Vaccine may not protect everyone. I understand that I should remain in the vaccine administration area 1/11/21 . Yes No 6. Informed consent form (ICF) template (for adult subjects) [DOCX] ICF addendum template [DOCX] ... Purpose of the last page of the consent document [PDF] Protocol Templates. I ask that the vaccine be administered to me. A few people may have no side effects at all. Talk to the vaccination provider if you have questions. Complete ONLY ONE of the following two options: 1.Consent by legal decision maker I consent to the above named person receiving the COVID-19 vaccine. increased risk of severe illness if infected with COVID -19. Code Dose Amt mL Vaccine Injection Code RN Init Vaccine Elig. (If this consent form is not signed, then this person will not be vaccinated) The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. Vaccine Administration Record Vaccine Type Vaccine Date Given (mo/day/yr) Route (IM, SQ) Site Given (RA, LA) Vaccine Information Statement Lot # Expiration Manufacturer Date on VIS Date Given Printed Name of Pharmacist Administering Vaccine Pharmacist’s Signature Store # Drug Protocol # and Physician’s Name IMMUNIZATION CONSENT FORM Vaccine Consent Form Valerie Crow, Cobb & Douglas Public Health 2021-03-29T19:56:28+00:00 Vaccine Consent Form If you have an appointment scheduled to receive the COVID-19 vaccine at Cobb & Douglas Public Health, please complete the COVID-19 Vaccine Consent Form before your appointment. DATE OF BIRTH month day _____ year PARENT / LEGAL GUARDIAN NAME (Last) (First) (M.I.) Guidance for Writing Protocols. Two clinics will be conducted to administer both the first dose and the second dose of the COVID-19 vaccine, with a third clinic date scheduled as a placeholder for any new admissions or new hires in need of completing the vaccine series. I understand there will be no cost to me for this vaccine. This vaccine has not completed the same type of review as an FDA-approved or cleared product. Wait at least 28 days after the last dose of the non-FDA-authorized vaccine before administering an FDA-authorized COVID-19 vaccine. COVID-19 Vaccine Consent Form WHAT TO DO IF YOU HAVE A REACTION TO THE COVID-19 VACCINATION Most people have side effects from the vaccination, but these usually only last 24 – 48 hours after receipt of the vaccination. See F11-11936 below. answers to my satisfaction and consent to the administration of the vaccine. COVID-Vaccine-Consent-Form-2021 12 AND UP.docx; COVID Vaccine Consent Form 2021.pdf; COVID-Vaccine-Consent-Form-2021 (2) (002) Spanish Completed.pdf If you require reading glasses, please bring those with you so that you can complete your consent form. receive the COVID-19 vaccine. A COVID-19 vaccine declination form is a consent collection document used for the purpose of getting a patient or a person's express intention to decline from receiving vaccination from COVID-19. There is a remote chance that a COVID-19 vaccine could cause a severe allergic reaction. Unless I provide KPH Healthcare Services, Inc. with a signed Op-Out Form, I understand that my consent will remain in effect until I withdraw my permission and that I may withdraw my consent by providing a completed Opt-Out Form to KPH Health Services, Inc. and/or my State HIE, as applicable. The risk of any vaccine causing serious harm, or death, is extremely small. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? If this is your second dose, when was the date of your first dose? At this time, we will recommend that you wear a mask in public and follow other safety precautions even after completing the COVID-19 vaccine series. a. Vaccine Preparer’s Signature: _____ Vaccine Administrator’s Signature: _____ Nurse’s Time Minutes Vaccine Dose # Brand Name Lot Number Exp. Have you received plasma within the last 90 days while sick in the hospital with COVID-19? Consent Forms for Minors and Adults: C-7 Immunization Registry (ImmTrac2) - Minor Consent Form - Bilingual (rev. I have had the opportunity to ask questions about the vaccine(s) which were answered to my satisfaction. Long weekend hours of operation: Please note that we will be running the vaccine clinic at Downsview Arena during the following times over the next couple of days: Saturday May 22, 2021 – 9 am – 4 pm. I understand the risks and Sunday May 23, 2021 – 9 am – 4 pm. COVID Vaccine Consent Form - Lascassas Drugs Vaccine is now available for everyone ages 18 and older (we carry Moderna brand so you have to be 18 to receive it) Section I. answers to my satisfaction and consent to the administration of the vaccine. COVID Consent Form Thank you for attending the Weber-Morgan Health Department COVID-19 Immunization Clinic. Available for PC, iOS and Android. COVID-19 Vaccine Consent Form Section 1: Information about Person to Receive Vaccine (please print) RESIDENT’S NAME (Last) ... person named at the top of this form to be vaccinated with this vaccine. ... Form Version: 3/15/21. I have read, or have had explained to me, the Emergency Use Authorization (EUA) for COVID-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction. Handy tips for filling out Publix Vaccine Consent Form online. COVID-19 vaccine but require parental/guardian consent to receive the Pfizer COVID-19 vaccine. There is no FDA-approved vaccine to prevent COVID … to receive the Covid-19 vaccination. There is no FDA-approved vaccine to prevent COVID … COVID Vaccine Consent Form - Wells Hometown Drug * Please fill out the required details below If you have remaining questions, please call us at 641-664-3100 Local symptoms may include: slight tenderness, redness, itching or swelling at the site of injection. The Moderna COVID-19 Vaccine may not protect everyone. Long weekend hours of operation: Please note that we will be running the vaccine clinic at Downsview Arena during the following times over the next couple of days: Saturday May 22, 2021 – 9 am – 4 pm. Dose #2 . The Moderna COVID-19 Vaccine is administered as a 2-dose series, 1 month apart, into the muscle. asked to sign a consent form on site. This authorization is given pursuant to the provisions of California Family Code Section 6910. Title: 2021 04 15 - COVID-19 Vaccine Consent Form Author: Mid Coast Parkview Health Created Date: 20210415171439Z February 16, 2021- Canceled COVID-19 vaccine appointments to be rescheduled over next three days January 27, 2021- Health department to begin vaccinating people age 65-69 years old for COVID-19 January 11, 2021- Health department schedules COVID-19 vaccination appointments for more than 12,000 people but demand exceeds availability I have read, had explained to me, and understand the information in the EUA. COVID Vaccine Intake Consent Form Clinic Information . 2. There is no FDA-approved vaccine to prevent COVID-19 at this time. • I understand that I may withdraw this consent at any time by informing the health care provider giving the COVID-19 vaccine. COVID-19 vaccine (for example, to remind you of follow up appointments and to provide you with proof of vaccination). Consent for services: I have been provided with the vaccine information sheet for the COVID19 vaccination that I am receiving. Who will be offering Phase 2D vaccinations? No. Are you feeling well today, and do you have a bodily temperature below (100 F)? COVID-19 Vaccine Information: 800-438-5795 (Weekdays 8 a.m.-5 p.m.) Email Us Home » Public Health Division » Immunization Unit » Wyoming COVID-19 Vaccine Information » COVID Vaccine Consent Form – Template We are happy to offer all three COVID-19 Vaccines every day at all three locations. I have been offered a copy of the COVID-19 Emergency Use Authorization (EUA). Download COVID-19 vaccination – Consent form for COVID-19 vaccination as Word - 285 KB, 4 pages We aim to provide documents in an accessible format. 4. VACCINATION CONSENT FORM Moderna COVID-19 Vaccine The novel coronarvirus SARS-CoV-2 (a/k/a COVID-19) is an infectious disease that appeared in late 2019. COVID-19 VACCINE PARENTAL CONSENT FORM . Systemic symptoms may include: fever, malaise and muscle pain. / / 14. I have had a copy of the Emergency Use Authorization for the COVID-19 vaccine made available to me. orders.pdf . Getting afflicted with COVID-19 risks the health and life of the infected … All Vaccine Recipients Must Sign The COVID-19 Vaccination Consent Form. COVID-19 vaccination consent form for adults who are able to consent (PDF version) Ref: PHE gateway number 2020376 PDF , 51.1KB , 1 page This … • I have had an opportunity to discuss my questions and concerns as they relate to the COVID-19 vaccine. COVID Vaccine Consent Form - Wells Hometown Drug * Please fill out the required details below If you have remaining questions, please call us at 641-664-3100 The COVID-19 vaccination is free. 2. We’ll keep you updated on the groups we’re currently vaccinating in your state as directed by the federal and state governments. If this is your second dose, which vaccine did you receive (Pfizer, Moderna, etc.)? By signing this consent you (agree for your child to receive both doses of the vaccine). • A previous dose of COVID-19 vaccine. Version 3.0 – March 11 2021 . *** Section I. However, women younger than 50 years old especially should be made aware of a rare risk of blood clots with low platelets following vaccination and the availability of other COVID-19 vaccines where this risk has not been observed. years of age; or (c) authorized to consent for vaccination for the patient named above. (F o r e xa mp l e : co l d , f e ve r, o r a cu t e i l l n e ss) D o yo u h a ve a b l e e d i n g d i so rd e r o r a re yo u o n a b l o o d t h i n n e r? Signed parental consent is required before anyone under the age of 18 will be vaccinated. If you're having problems using a document with your accessibility tools, please contact us for help . I am an adult who can legally consent for the person named below to receive the COVID-19 vaccine. However, women younger than 50 years old especially should be made aware of a rare risk of blood clots with low platelets following vaccination and the availability of other COVID-19 vaccines where this risk has not been observed. THE VAX FACTS There is a lot of information out there about COVID-19 vaccines, and some of it may be confusing. Consent I have been provided and have read, or had explained to me, the information sheet about the COVID-19 vaccination. I have been offered a copy of the COVID-19 Emergency Use Authorization (EUA). I have received the VIS Form and the Discount Drug Mart NOPP. If you consent to receiving these follow up communications by email or text/SMS, please indicate this using the boxes below. I understand the risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization F act Sheet on the COVID-19 vaccine I have elected to receive. Talk to the vaccination provider if you have questions. COVID Vaccine Consent Form * Please fill out the required details below If you have remaining questions, please call us at (919)377-0342. * yes no 2. in the last 90 days have you received passive antibody therapy (monoclonalantibodies or convalescent plasma) as part of yes no . Label size: 2/3” x 1¾” ) Split-dose box labels 75 (For use with Avery 6870. I give my consent to the certified immunizer at Food City Pharmacy to administer the vaccine(s) listed below. Additional Information About COVID-19. Once you have submitted your information, a PDF of the contract will download automatically. Vaccine Resources for Healthcare Providers; Immunization Forms, Brochures and Memos; Influenza Season; COVID-19 Vaccine Information For the General Public; COVID-19 Vaccine Information For Health Care Providers The UKMFA have produced a referenced consent form for use by doctors and their patients to aid the process of obtaining full informed consent before having a COVID-19 vaccine. If you receive one dose of the Moderna COVID-19 Vaccine, you should receive a second dose of the same vaccine 1 month later to complete the vaccination series. Title: 2021 04 15 - COVID-19 Vaccine Consent Form Author: Mid Coast Parkview Health Created Date: 20210415171439Z Vaccination eligibility varies by state. I Open PDF file, 156.95 KB, for MA Consent Form for Individuals Under 18 Years of Age - Arabic - 5/19/21 (PDF 156.95 KB) 2020-2021 season . By signing the consent, I acknowledge that I understand the following: The FDA has authorized the emergency use of the Johnson & Johnson COVID-19 Vaccine that may prevent COVID-19. There is no FDA-approved vaccine to prevent COVID-19 at this time. Please read carefully and ask any questions before you sign. 02/2021) Use this form to register your child, aged 17 and younger, in ImmTrac2. Yes No If yes, which vaccine/medication? You can view a list of other providers using the All Vaccine Providers tab on our Vaccine Clinic Dashboard or COVID-19 Table. Tuesday May 25, 2021 – 10 am – 6 pm 1. This vaccine has not completed the same type of review as an FDA-approved or cleared product. AGE GENDER M / F COVID-19 VACCINE CONSENT FORM. I understand that in the course of the requested vaccine administration, an H-E-B Pharmacy representative could possibly be exposed to my blood or bodily fluids. I have had a chance to ask questions that were answered to my satisfaction. Fill in the empty areas; involved parties names, places of residence and phone numbers etc. A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. Renown’s vaccine clinic will remain open through June 4 for individuals who received their first dose of the vaccine through Renown have the opportunity to receive their second dose. • A previous dose of COVID-19 vaccine. Consent Form. I 2. I have read, had explained to me, and understand the information in the EUA. COVID-19 VACCINATION ADMINISTRATION RECORD Sangamon County Department of Public Health 2833 South Grand Avenue East, Springfield, IL 62703 (217) 535-3100 Tax ID #37-6002039 NPI #1164448262 d H ID PLEASE PRINT AND BRING THIS FORM TO APPOINTMENT Please PRINT information about the person to receive the vaccine: Monday May 24, 2021 – CLOSED. COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I believe I understand the benefits and risks of the vaccine. The FDA has made the COVID-19 vaccine available under an emergency use authorization (EUA). • I confirm that I have the legal authority to consent … I know that the person named below will have the COVID-19 vaccine injected into their body to prevent the COVID-19 disease that the COVID-19 vaccine is meant to prevent. VACCINATION CONSENT FORM Pfizer-BioNTech COVID-19 Vaccine The novel coronarvirus SARS-CoV-2 (a/k/a COVID-19) is an infectious disease that appeared in late 2019. See F11-11936 below. If No If Yes – allow to schedule –“Defer vaccination until improvement in symptoms for I Start a free trial now to save yourself time and money! Your answers to the questions should reflect your current health status. … Find the PDF COVID-19 VACCINE SCREENING AND CONSENT FORM - Florida ... you need. Most people will experience pain, redness and/or soreness at the injection site. 5. ... COVID-19 vaccine series authorized for emergency use by WHO may be offered an FDA-authorized COVID-19 vaccine series. 4. COVID-19 Vaccine Consent Form . INFORMED CONSENT FOR ADMINISTRATION OF COVID-19 VACCINE This consent form contains important information to help you decide whether to have the Covid-19 vaccine. A few people may ... COVID-19 Vaccine Update. Getting afflicted with COVID-19 risks the health and life of the infected … COVID-19 Screening Questions Yes No 1. Date Manuf. A COVID-19 vaccine registration, consent, and appointment form is a screening form used by vaccine providers to collect health information and informed consent from their patients while simultaneously scheduling vaccine appointments. Email address Phone Number . Form reviewed by Date 1. COVID-19 Vaccine Consent Form 500 Eisenhower Rd Suite 101 Leavenworth Kansas 66048 913.250.2000 WHAT TO DO IF YOU HAVE A REACTION TO THE COVID-19 VACCINATION • Most people have side effects from the vaccination, but these usually only last 24 – 48 hours after receipt of the vaccination. SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT) Last Name . • A vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction. The official COVID-19 vaccination consent form in Malaysia has been released, and is available online and in the MySejahtera app. I am an adult who can legally consent for the person named below to receive the COVID-19 vaccine. I also understand that should I elect to receive the COVID-19 vaccine, the provider must enter my information into the "Iowa Immunization Registry Information System." I have reviewed the contents of this Registration and Consent Form with patient/parent of patient/guardian of
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