I declare that I or my child is 16 years of age or older. I further declare that I or my child:
1. Have not experienced anaphylaxis (difficulty breathing) or severe allergic reactions from a previous vaccination or an injectable medication.
2. Have not had any other vaccinations in the previous 14 days (e.g. MMR, Shingrix, Varicella, or a TB skin test).
3. Is not currently sick with a fever, active respiratory infection or other moderate/severe illness.
4. Has have not received monoclonal antibodies or convalescent plasma for treatment of COVID-19 within the past ninety (90) days.
5. Is not allergic to the following ingredients in the COVID-19 vaccine: mRNA, lipids4-hydroxybutyl)azanediyl)bis(hexane-6, 1-diyl)bis(2-hexyldecanoate),2[(polyethylene glycol)-2000]-N, N-ditetradecylacetamide, 1, 2-Distearoyl-sn-glycero-3-phosphocholine,and cholesterol), potassium chloride, monobasic potassium phosphate, sodium chloride, dibasic sodium phosphate dihydrate and sucrose.
I understand that if I or my child have any of the above conditions, I or my child could be at increased risk of having a negative reaction or problem from the vaccine. I further declare that if I or my child have any of the following conditions, I have had the opportunity to speak with my or my child's primary care provider and am making an informed decision to receive the vaccine or to have my child receive the vaccine:
1. Pregnant, attempting to become pregnant or breastfeeding;
2. Have a bleeding disorder or are on a blood thinner;
3. Are immunocompromised or are taking a medication that affects the immune system (such as cortisone, prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease or psoriasis; HIV/AIDS, cancer, leukemia, ankylosing spondylitis or radiation treatments).
I agree to WAIT near the clinic location for 15 minutes after receiving the vaccine. If or my child have previously had a severe allergic reaction to a vaccine or injectable medication, I agree to WAIT near the clinic location for 30 minutes after receiving the vaccine.
I understand that the COVID-19 vaccine is a two-part vaccine series. By signing this consent, I am agreeing that I or my child will receive the first and second part of the vaccine series.
I understand that the common risks associated with the COVID-19 vaccine include but are not limited to pain, redness or swelling at the site of injection, tiredness, headache, muscle pain, chills, joint pain, fever, nausea, feeling unwell or swollen lymph nodes (lymphadenopathy). I understand that the vaccine may cause a severe allergic reaction which can include anaphylaxis (difficulty breathing, swelling of the face and throat, a fast heartbeat, a rash all over the body, dizziness and/or weakness I understand that these may not be all the side effects of the COVID-19 vaccine as the vaccine is still being studied in clinical trials. I also understand that it is not possible to predict all possible side effects or complications which could be associated with the vaccine. I understand that the long-term side effects or complications of this vaccine are not known at this time.
I understand that the vaccination is being given by American Executive Health System (AEHS). The owner and/or operator of this site, their affiliates, officers, directors, and disclaim any responsibility for the vaccination. My consent is given in light of this knowledge, and in consideration of I giving the COVID-19 vaccine. I, for myself and my heirs, administrators, trustees, executors, assigns and successors in interest do hereby agree to release and hold harmless AEHS, its subsidiaries, divisions, affiliates, successors, assigns, officers, trustees, employees, volunteers and agents from and against any and all demands, damages, losses, costs, expenses, obligations, liabilities, actions and cause of action (whether any of which is groundless or otherwise) of any nature whatsoever (including, without limitation, reasonable attorney's claims, fees and court costs) by reason of or resulting, in any way, from any and all acts, accidents, events, occurrences, omissions and the like related to, or arising out of, directly or indirectly, receipt of this COVID-19 vaccine. AEHS makes no warranties, express or implied, including but not limited to, implied warranties of merchantability or fitness for a my particular purpose regarding the vaccine or its effectiveness.
Medicare Part B Recipients: I understand AEHS will process Medicare Part B claims on my behalf and accepts Medicare payment.
Private Insurance Participants: I understand AEHS will process insurance claims on my behalf and accepts insurance payment.
I have read and understood "What to expect after vaccine & V-safe" by CDC and the "Fact Sheet" by the FDA regarding the COVID-19 Vaccination. I further understandand agree that AEHS is required to submit COVID-19 vaccine administration data the Vaccine Administration Management System (VAMS).
I understand and agree to all of the above and I hereby give my consent to the staff of AEHS to give me or my child a COVID-19 vaccine.