COVID Vaccine Consent Form

Patient's Full Name: *

First Name Ml Last Name

Today's Date: *

Birth Date *

Month Day Year

Age *

Gender: *

Male Female

Address: *

Street Address Line 2

Phone Number: *

Parent's Email: *

Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer

Race: *

American Indian or Alaska Native Asian Black or African America Native Hawaiian Other Pacific Islander White

Has the person listed above previously received COVID-19 vaccine? *

No Yes

If yes to the above, which COVID vaccine was previously received?

Pfizer for ages 5-11 Pfizer for ages 12 years of age of older Moderna Johnson & Johnson

What dose of COVID-19 vaccine will this be? *

First Dose Second Dose Booster Dose

What date was your child's most recent COVID-19 vaccine received on? *

Date

Do you have insurance that covers vaccines?

Yes No I don't know

Indicate the child's eligibility status for the Vaccine for Children (VFC) Program? *

is enrolled in Medicaid does not have health insurance is American Indian or Alaskan Native (AI/AN) is underinsured (has health insurance that DOES NOT pay for vaccinations) [Can only received VFC vaccine at Federally Qualified Health Center (FQHC), rural health clinic (RHC), or local public health (LPHA)] Is not eligible for the VFC Program because they do not meet the above criteria

Please select the correct option below: *

	Yes	No
Are you feeling sick today?
Have you been treated with antibody therapy for COVID-19 in the past 90 days?
Have you been diagnosed with multisystem inflammatory syndrome in children (MIS-C)?
Have you had a serious or life-threatening allergic reaction, such as hives, or difficulty breathing to ANY vaccine or shot?
Have you had any vaccines in the past 14 days (including the flu)?
Are you pregnant, considering becoming pregnant or breastfeeding?
Do you have cancer, leukemia, HIV/AIDS, history of autoimmune disease or any other conditions that weakens the immune system?
Do you take any medications that affect your immune system such as steroids, anticancer drugs or have you had an radiation treatments?

Emergency Use Authorization

The FDA has made the COIVD-19 avaccine avaialble under an emergency use authorization (EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. This vaccine has not completed the same type of review as an FDA-approved or licensed vaccine. However, the FDA's decision to make the vaccine available under an EUA is bsed on the existence of a public health emergency and the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks.

Information on the Risks and Benefits of the Pfizer COVID-19 Vaccine

The Pfizer-BioNTech (Pfizer) COVID-19 Vaccine "Fact Sheet for Recipents and Caregivers" is available at https://www.fda.gov/media/153717/download.

Paren or Guardian Consent for Minor Vaccination

I have reviewed the information on risks and benefits of the Pfizer COVID-19 Vaccine above and understand the risks and benefits. In providing my consent below, I agree that:

Please check the following *

1. I have reviewed this consent form, and I understand that the "Fact Sheet for Recipients and Caregivers," includes more detailed informaiton about the potential risks and benefits of the Pfizer COVID-19 vaccine.

*

2. I have the legal authority to consent on behalf of the child/minor named above to vaccinations with the Pfizer COVID-19 Vaccine.

*

3. I understand I may not be required to accompany the child/minor named above to their vaccination appointment and that, by giving my consent below, the child/minor will receive the Pfizer COVID-19 Vaccine whether or not I am present at the vaccination appointment.

I GIVE CONSENT for the child/minor named at the top of this form to get vaccinated with the two-dose Pfizer COVID-19 Vaccine and have reviewed and agree to the information included in this form. The scope of this consent includes administration of the vaccine, discussion with a provider if requested, care and treatments immediately after administration as needed (If this consent is not signed, dated and returned, the child/minor will not be vaccinated.)

Parent/Guardian Name *

First Name Last Name

Relationship to Minor: *

Signature of Parent/Guardian *

Clear

Appointment *

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.

Pfizer Ages 5-11 - COVID Vaccine Consent Form