• Prevaccination Checklist for COVID-19 Vaccines

    The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.
  •  - -
    Pick a Date
  • Consent

    • I certify that I am: (a) the patient and at least 18 years of age; (b) the parent or legal guardian of the patient and confirm that the patient is at least 16 years of age; or (c) authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to Santa Clarita Pharmacy to administer the COVID-19 vaccine.
    • I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 12 years os age and older (Pfizer vaccine) or 18 years of age and older (Moderna or Janssen vaccine); and the emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.
    • I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). 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 Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.
    • I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation; and for 30 minutes if I have a history of anaphylaxis from any cause. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.
    • On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Family Matters DPC, and their staff, associates, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.
    • I acknowledge that: (a) I understand the purposes/benefits of CA-SIIS, California's immunization registry and (b) will include my personal immunization information in CA-SIIS and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies.
    • I acknowledge receipt of the Notice of Privacy Rights.
  • By signing, I have completed this form to the best of my knowledge and consent to the agreement as written and receipt of vaccine.

  • Clear
  • Should be Empty: