If getting a 3rd Shot or Booster Dose
MacDonald Auditorium in Ken Olson Science Center
ENTER via Lower Level
Booster Shot Eligibility
The parent or guardian does NOT need to go with the minor to their vaccination appointment to give consent. Please review the below information and PARENT or GUARDIAN can sign for consent here electronically
Information on the risks and benefits of a COVID-19 Vaccine
Your child is being offered a COVID-19 vaccine made by Pfizer-BioNTech. The PfizerBioNTech COVID-19 Vaccine is approved by the U.S. Food and Drug Administration (FDA) for people over 16 years old, with the brand name Comirnaty. The FDA has also issued an Emergency Use Authorization for Pfizer-BioNTech COVID-19 Vaccine for people ages 5 and older. Both the Pfizer-BioNTech COVID-19 Vaccine and Comirnaty are administered as a 2-dose series, 3 weeks apart, into the muscle.
The vaccine provider will need certain information about your child’s medical history before administering the vaccine. Those questions are available here www.mass.gov/CDCScreeningForm
The vaccine may not protect everyone from COVID-19 disease. Some people mayexperience side effects after getting the vaccine. Side effects that have been reported include injection site pain, tiredness, headache, muscle pain, chills, joint pain, fever, injection site swelling, injection site redness, nausea, feeling unwell, and swollen lymph nodes. There is a remote chance that the vaccine could cause a severe allergic reaction. A severe allergic reaction would usually occur within a few minutes to one hour after getting a dose of the vaccine. For this reason, a vaccination provider may ask the person receiving the vaccine to stay at the place where they received their vaccine for monitoring after vaccination. Signs of a severe allergic reaction can include difficulty breathing, swelling of the face and throat, a fast heartbeat, and/or a bad rash all over the body.
Additional information is available in the Pfizer-BioNTech COVID-19 Vaccine “Fact Sheet for Recipients and Caregivers” available at:
• Recipients and Caregivers 5-11 years of age (fda.gov) https://www.fda.gov/media/153717/download • Recipients and Caregivers 12 years of age and older (fda.gov) https://www.fda.gov/media/153716/download
CONSENT FOR MINOR’S VACCINATION:
I have reviewed the information about the PfizerBioNTech and Comirnaty COVID-19 Vaccines in Section 2 above and understand the risksand benefits. In providing my consent below, I agree that:
I GIVE CONSENT for the child named at the top of this form to get vaccinated with the Pfizer-BioNTech or Comirnaty COVID-19 Vaccine and have reviewed and agree to the information included in Section 3 of this form. (If this consent is not signed, dated, and returned, the child will not be vaccinated.)
Conformation email will be sent from JotForm.com