Patient Emergency Contact: (For emergency only such as passing out or needing to be taken to a hospital)
Please answer the questions below to help us determine if there is any reason you should not get the COVID-19 vaccine today. If you need help, please ask a staff person.
Informed Consent: I answered all the questions correctly to the best of my knowledge. I have read or have had explained to me the information contained in the EUA Fact Sheet or VIS about COVID-19 disease/vaccine. I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of the vaccine and request this vaccine be given to me or to the person named above for whom I am authorized to make this request. I answered all the questions correctly to the best of my knowledge.
I ACKNOWLEDGE THAT A COPY OF THE "NOTICE OF PRIVACY PRACTICE" HAS BEEN MADE AVAILABLE TO ME.