I understand that the COVID-19 vaccine is a voluntary vaccine currently being given under the Emergency Use Authorization status and only a parent or legal guardian has the authority to consent to a minor or adult conservatee receiving this vaccine. By signing this form, I certify that I have legal authority to do so on behalf of the patient identified.
I have read or had explained to me the information contained in the Emergency Use Authorization Fact Sheet for Recipientsand Caregivers - Moderna for the COVID-19 vaccine and understand the risks and benefits of the vaccine. I have had a chance to ask questions which have been answered to my satisfaction and understand the benefits and risks of the vaccine. I, on behalf of myself, my heirs, executors, and personal representatives hereby agree to release, indemnify, and hold harmless Tosa Pediatrics, its subsidiaries, affiliates, agents, owners, providers, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine.
I acknowledge disclosure of this vaccination to public health officials and other health care professionals. I understand this vaccine will be recorded in the Wisconsin Immunization Registry (WIR) for the purposes of sharing vaccination information with other health care providers and tracking vaccine inventory only.
In the event of an emergency situation, emergency medication (Epinephrine/Benadryl) and/or oxygen may be administered to my child or adult conservatee. In the event of an emergency situation where I am not present, I authorize Tosa Pediatrics' staff to obtain any necessary medical care they deem necessary including but not limited to, obtaining paramedic assistance and transport to a local hospital for additional treatment or observation.