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COVID-19 Vaccine Consent Form

To download a paper copy of this form, please click here.

Patient Info

Insurance Info

Please answer the health questions below.
Please acknowledge the following:

I have been given a copy and have read, or have had explained to me, the information in the Vaccine Information Statements for the vaccines indicated. I have had the chance to ask questions that were answered to my satisfaction. I believe that I understand the benefits and risks of the vaccines requested and ask that the vaccines indicated be given to me or the person named for whom I am authorized to make this request.

It is suggested that anyone getting a vaccine stay for 15minutes after getting vaccinated before leaving.

Those with previous anaphylactic reactions should stay for 30 minutes.

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