• COVID Vaccine Consent Form

    COVID Vaccine Consent Form

    * Please fill out the required details below
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  • If you have remaining questions, please call us at (336)-570-2273.
  • Section I. Personal Information
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  • Section II. Appointment Scheduler

  • Section III. Signatures I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), (Moderna) a copy of which is linked above and will be provided at my appointment. 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 and Release.

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  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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