I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which was provided to me at the time of registration. I have had a chance to ask questions that were answered to my satisfaction.
I agree to WAIT near the clinic location for 15 minutes after receiving the vaccine. If I or my child have previously had a severe allergic reaction to a vaccine or injectable medication, I agree to WAIT near the clinic location for 30 minutes after receiving the vaccine.
I understand that the COVID-19 vaccine is a two-part vaccine series. By signing this consent, I am agreeing that I or my child will receive the first and second part of the vaccine series.
I understand that the vaccination is being given by Kim A. Kelly MD, PC. The owner and/or operator of this site, their affiliates, officers, directors, employees and agents expressly disclaim any responsibility for the vaccination. My consent is given in light of this knowledge, and in consideration of Kim A. Kelly MD, PC giving the COVID-19 vaccine. I, for myself and my heirs and family members, administrators, trustees, executors, assigns and successors in interest do hereby agree to release and hold harmless Kim A. Kelly MD, PC, its subsidiaries, divisions, affiliates, successors, assigns, officers, trustees, employees, volunteers and agents from and against any and all demands, damages, losses, costs, expenses, obligations, liabilities, claims, actions and cause of action (whether any of which is groundless or otherwise) of any nature whatsoever (including, without limitation, reasonable attorney’s fees and court costs) by reason of or resulting, in any way, from any and all acts, accidents, events, occurrences, omissions and the like related to, or arising out of, directly or indirectly, my receipt of this COVID-19 vaccine.
I further understand that my provider is required to submit COVID-19 vaccine administration data to ImmuNet, Maryland's Immunization Information System. I was also offered a copy of the Kim A. Kelly MD, PC Notice of Privacy Practices at the time of registration.
Pfizer EUA 12 and up
Pfizer EUA 5-11
Notice of Privacy Practices