• Pfizer Ages 6mo-4 - COVID Vaccine Consent Form

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  • 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 Pfizer EUA

     

  • 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:

     

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    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.)

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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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