• Children's (*5-11yr old) Covid Primary & Bivalent Vaccine Consent Form

    Children's (*5-11yr old) Covid Primary & Bivalent Vaccine Consent Form

    * Please complete required details below. If you have questions, please call us at (803) 649-1776 or (803) 648-1776.
  • Section I. Personal Information
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  • Section II. Questionnaire for Immunization
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  • Section III. Appointment Scheduler
  • **Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.** 

  • Section IV. Signatures I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (insert link to EUA), a copy of which I was provided with this Consent and Release. 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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