By signing this form, I acknowledge that my doctors office provided me with the Covid-19 vaccine EUA sheet. I declare that the information I have provided above is correct. I am giving my full consent to get the COVID-19 vaccine. I hereby acknowledge that I have received a copy of Parkwood Pediatric Group Notice of Privacy Practices, Billing Policy and Assignment of Benefits. See attachments below for Covid-19 EUA & PPG Policy information. Please confirm with Parkwood Pediatric Group that we have the most up to date insurance for you. We can be reached at (843)556-8110 for insurance updates and/or any questions or concerns.