COVID-19 Vaccine Consent Form

COVID-19 Vaccine Consent Form

Covid-19 Vaccine 6m-5yrs
Patient's Name

First Name Last Name
Patient's Date of Birth

Month Day Year
Date
Parent's Name

First Name Last Name
Parent's Email
example@example.com
Parent's Phone

Area Code Phone Number
I have read/had explained to me, and understand the COVID-19 vaccine emergency use authorization (EUA)sheet. I am the parent or legal guardian of the above child, I have the authority to make healthcare decisions for the child, and I give my permission for the child to receive COVID-19 vaccine. I understand the benefits and risks of COVID-19 vaccine. I understand my child's immunization information will go into a state database.
Parent/Guardian Signature

Clear
Today's Date

Month Day Year
Date
Should be Empty: