I will/have reviewed my answers to the questions above with the vaccinator. If I experience any adverse reactions after leaving, I will notify my primary care provider. I have viewed the Emergency Use Authorization Fact Sheet provided to me today. I understand the benefits and risks of the vaccine. I understand that I can review a Notice of Privacy Practice at the time of vaccination.
By signing this form, I give permission for a vaccine to be administered to the person above and a record of the vaccination to be entered into the Maryland's Immunization Information System (Immunet) for care coordination and to monitor statewide vaccination coverage. For more information about the vaccine and distribution, please go to https://www.cvdvaccine-us.com/. Further, I agree that the information above is correct.