5-11 Pfizer sign-up and consent

What is your preferred location

Guthrie Center 11/16/21Panora 11/17/21Stuart 11/18/21Panora 11/20/21
Guthrie Center
Panora
Stuart
LPA Conference Center
Vaccine Consent

I have read or have had explained to me the information provided in the Emergency Use Authorization (EUA) Factsheet or Vaccine Information Statement about COVID-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of COVID-19 vaccine and ask that the vaccine be administered to me.
Guardian Name

First NameLast Name
Signature of Guardian

Clear
Consent date

MonthDayYear
Date
You or another adult like a Covid vaccine?

YesNo
Please list the names and date of births of the adults that would like a shot at the same time.
Should be Empty:

Covid 19 Vaccine Sign up and Consent