Clone of Patient Intake Form - Short minor Consent

Intake Form for the Pfizer COVID-19 Vaccine

Consent for Individuals Under 18 Years of Age
Patient Information

Person receiving the vaccine:
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Primary Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Section 2
Section 2: Information on the risks and benefits of the Bivalent Pfizer/Moderna-COVID-19 Vaccine.

Currently the U.S. Food and Drug Administration (FDA) has authorized emergency use of the Moderna/Pfizer Bivalent Vaccine to prevent COVID-19 in individuals 5 year for Pifzer, and 6+ for Moderna. The FDA has not yet approved licensure of vaccine to prevent COVID-19 for minors. To learn more about risks, benefits, and side effects of the COVID vaccine, read the U.S. Food and Drug Administration’s Fact Sheet for Recipients and Caregivers – here is a version specifically for 5-11 year old vaccine recipients, and here is a version for those minors between the ages of 12-17.

Section 3: Consent. I have reviewed the information on risks and benefits of the Bivalent Pfizer/Moderna Vaccine. in Section 2 above and understand the risks and benefits.

I agree that:

1. I reviewed this consent form and have read and understand the “Fact Sheet for Recipients and Caregivers” about the potential risks and benefits of the Bivalent Pfizer/Moderna Vaccine.

2. I have the legal authority to consent to have the child named above vaccinated with the Bivalent Pfizer/Moderna Vaccine.

3. I understand I am not required to accompany the child named above to the vaccination appointment and, by giving my consent below, the child will receive the Bivalent Pfizer/Moderna Vaccine whether or not I am present at the vaccination appointment.

4. I understand that as required by state law (Health and Safety Code, § 120440), all immunizations will be reported to the California Immunization Registry (CAIR2). I understand the information in the child's CAIR2 record will be shared with the local health department and State Department of Public Health, shall be treated as confidential medical information, and shall be used only to share with each other or as allowed by law. I may refuse to allow the information to be further shared and can request the CAIR2 record be locked by visiting the Request to Lock My CAIR Record web form.

I GIVE CONSENT for the child named at the top of this form to get vaccinated with the Bivalent Pfizer/Moderna Vaccine and have reviewed and agree to the information included in this form.
Parent/Guardian's Name:*

First NameLast Name
Date Signed*

MonthDayYear
Date
Relationship to Patient:*
Signature of legally authorized representative or independent minor*

Clear
Should be Empty:

Intake Form for the Pfizer COVID-19 Vaccine

Patient Information

Section 2