1/12 WSSD School District 5-11 & BOOSTERS COVID-19 Consent Form

First Dose Second Dose Booster

Sorry, if the person you are registering does not meet the recommendations for the Booster shot, we can not give it at this time. Thank You

Moderna Pfizer Johnson & Johnson

5 - 11 year olds 12 - 17 year olds 18 and above

Date of your initial Pfizer vaccination

First Name Last Name

The Pfizer vaccine is approved for people ages 5 and up.

Address

Street Address Line 2

City State

Zip Code

Medicaid Medicare Part B Private Insurance No Insurance

Social Security State ID #

I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent & 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 & Release. I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy & of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information. I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.

Please Print

BEFORE YOU CLICK SUBMIT, PLEASE FOLLOW THE STEPS BELOW:

1. Click Preview PDF button below.
2. Print your form by clicking the printer icon (top right of the screen)
3. Click "Back to Form" (top left of your screen)
4. Hit Submit
5. Bring your form and insurance card to the clinic.

For each individual person that recieved their vaccine with us on December 20 a new consent form will need to be completed.

Please complete the PDF below, print it, and bring it with you to the clinic on Wednesday 1/12.

Your appointment is at the same time as their first shot. You will also need to bring their vaccination cards and your ID. Thank You!

COVID-19 VACCINE SCHEDULING & CONSENT FORM

Insurance Information For The Person You Are Registering