COVID Vaccine Consent (FILL OUT ON SHOT DAY)

Consent for Immunization
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
I have been given a copy and have read, or have had explained to me, the information provided by the Centers for Disease Control (CDC) for the COVID-19 vaccine I/my child am to receive today.

I have had a chance to ask questions and they have been addressed to me satisfaction.

I understand the benefits and risks of the COVID-19 vaccine to be given.

I give my consent for the COVID-19 vaccine to be given to me/my child at this time.
Name of Parent/Guardian/Patient (if over 18 yrs of age): *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

COVID-19 Immunization Questionnaire