Pfizer COVID-19 Vaccine Appointment (Dose 2)
Dougherty's Pharmacy | Preston Valley Location
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Consent (check each box below after reading and prior to signing the form)
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I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet
Dougherty's Fact Sheet is available at the above link. A copy of which will be available at location. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I understand that at this time, the COVID-19 Pfizer vaccine requires 2 doses
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I authorize you to charge my medical insurance.
I understand that I will be receiving the vaccination at no out of pocket cost to me
Signature of Person to Receive Vaccine
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