The Pfizer-BioNTech COVID-19 Vaccine is an unapproved vaccine that may prevent COVID-19. Section 1: Information about Child to Receive Vaccine (please print) STUDENT’S NAME (Last) (First) (M.I.) • I have had an opportunity to discuss my questions and concerns as they relate to the COVID-19 vaccine. What COVID-19 vaccination is provided? For your second dose, you will receive a vaccine by the same manufacturer, and it will be administered at the recommended interval (21 days for Pfizer … I further acknowledge that: 1. A consent form is filled out for the Pfizer/BioNTech Covid-19 vaccine. MUST. COVID Vaccine Consent Form Jewel COVID-19 Vaccine Consent Form Step 3: Schedule Your Appointment On the day of your appointment, please remember to bring your completed consent form (from step 2) and your ticket with the QR code (issued after registration). Page 1 of 2 Pfizer BioNTech COVID-19 Vaccine Effective Date: 12/21/2020 COVID-19 VACCINE SCREENING AND CONSENT FORM Pfizer-BioNTech COVID-19 Vaccine SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT) Name: Last: First: Middle Initial: Date of Birth: Month Day Year Mobile Phone Number (Patient or Guardian): Hoja informativa para la vacuna Moderna. Do you have a bleeding disorder or are you on a blood thinner? Q: I got my first dose somewhere else. I understand the risks and benefits of the vaccination. If you need information about COVID-19, COVID-19 vaccines or help with the COVIDSafe app, call 1800 020 080. The Pfizer COVID-19 vaccine should be given to the person named above for whom I am authorized to make this r equest. 1. About COVID-19 vaccination People who have a COVID-19 vaccination have a much lower chance of getting sick from the disease called COVID-19. Jordan Valley Community Health Center. I understand that the Pfizer-BioNTech COVID-19 Vaccine is a vaccine that may prevent COVID-19. COVID-19 Vaccine JAN 02513153 0.5 mL . Youth age 12 – 17 do not have to have a parent present but must have a consent form signed by a parent. COVID-19 Vaccine Consent Form COVID-19 vaccine consent 2021 Consent to Receive the COVID-19 Vaccine I have been provided with the vaccine information sheet(s) corresponding to the COVID-19 vaccine I am receiving. I recommend it. The Pfizer-BioNTech and Moderna vaccines require two doses for you to be fully protected against COVID-19. To our partnering facilities in the CVS Health/Omnicare COVID -19 Vaccine Clinic Program – With ongoing input and additional clinical data from the CDC and vaccine manufacturers Pfizer and Moderna, we are updating our COVID-19 Vaccine Consent Forms. Minor Consent Form (English) I have been provided an opportunity to ask questions about the virus and the treatment. COVID-19? Clackamas County and our local vaccination partners have begun administering the vaccine for 12- to 15-year-olds. All individuals will receive the Pfizer-BioNTech vaccine. Has this person been vaccinated with the COVID-19 vaccine? for _____ to receive the COVID-19 vaccine. covid-19 (01/2021) covid-19 vaccine screening and consent form pfizer-biontech covid-19 vaccine . Consent to Receive the COVID-19 Vaccine (Pfizer) ... All students must have a signed consent form to receive the vaccine. IM Form COVID-19 Pfizer Vaccine Consent Form . Pfizer-BioNTech COVID-19 vaccine should be administered alone with minimal interval ... • I give consent to this COVID-19 provider/staff for the individual named above to be vaccinated with COVID-19 vaccine. COVID-19 Vaccination Consent Form Update . March 11, 2021: COVID-19 Vaccine Consent Form: Used by health care providers to obtain consent from patients for the COVID-19 vaccination. In order for a minor to receive the Pfizer vaccine, they must be accompanied by a parent or guardian or have one of the below consent forms completed. This is currently the only COVID-19 vaccine authorized for ages 12-17 in Canada. Page 1 of 2 Pfizer-BioNTech COVID-19 Vaccine Effective Date: 12/21/2020 COVID-19 VACCINE SCREENING AND CONSENT FORM Pfizer-BioNTech COVID-19 Vaccine SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT) Name: Last: First: Middle Initial: VACCINATION CONSENT FORM FOR MINORS 1 ver: 5-24-21 . Consent 05.2021v2 • I certify that I am: (a) the parent or legal guardian of the patient and confirm that the patient is at least 12 years of age; or (b) authorized to consent for vaccination for the patient namedFurther, above. My consent applies to all doses of the vaccine necessary to complete the series up to one year. The patientwas asked to join the V … I know the Food and Drug Administration (FDA) has authorized the emergency use of this vaccine. Vial labels and cartons may state that a vial contains 5 doses of 0.3 mL. Vaccine Administration Record (VAR)—Informed Consent for Vaccination SECTION C I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient; or (c) a person authorized to consent on behalf of the patient where the patient is not otherwise competent or unable to consent Vaccination Overview What is the status of a COVID-19 vaccine in Hawai‘i? COVID-19 VACCINE SCREENING AND CONSENT FORM. • has a severe or unusual side effect after the first dose of the COVID-19 vaccine (other than the expected side effects listed on the COVID-19 vaccine information sheet) I consent to this person getting the (only select one): mRNA COVID-19 vaccine (Pfizer-BioNTech or Moderna vaccine, depending which one they can get for their age) Consent Form – note: this is a fillable PDF form. Further, I hereby give my consent to the Heart of Florida Health Center, Inc. (HFHC) or its agents to administer the COVID-19 vaccine. The Moderna COVID-19 Vaccine vaccination series is 2 doses given 1 month apart. Vaccine@ontario.ca. COVID-19 Consent Form (Printable) V-Safe Information Sheet; Pfizer Required Fact Sheet for Patients; Fill out your COVID-19 Vaccine Consent Form Here. Help for 16-17 year-olds: Minors ages 16 and 17 (Pfizer vaccine only) must be accompanied by an adult or bring a signed consent form with them to the clinic: KPHD-MinorVaccineConsentForm.pdf (kitsappublichealth.org). I have the legal authority to consent to have the child named above vaccinated with the Pfizer-BioNTech COVID-19 Vaccine. Saturday, May 22nd. COVID-19 vaccine is given, and the risks associated with the COVID-19 vaccine. 9:00am - 2:00pm Please do not fill out a consent form until you have an appointment scheduled. Pfizer-BioNTech COVID-19 Vaccine Consent and Screening Form for Individuals Under 18 Years of Age The Pfizer-BioNTech COVID-19 Vaccine may prevent the person vaccinated from getting COVID-19. COVID-19 Vaccine (PFI) PFI 02509210 0.3 mL . It is recommended that children ages 12 years and older be vaccinated against COVID-19. 5. X Consentimiento de la Vacuna para el COVID-19. (If this consent form is not signed, then you child will not be vaccinated) 2801 Miller Ave, Fort Worth, Texas, 76105 The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. Global Information About Pfizer‑BioNTech COVID‑19 Vaccine (also known as BNT162b2) The approval status of the Pfizer‑BioNTech COVID‑19 Vaccine varies worldwide. 5/11/2021 Pfizer-BioNTech COVID-19 Vaccine Consent and Screening Form for Individuals Under 18 Years of Age Section 1: Information About Minor Child to Receive Vaccine … All COVID-19 vaccines were tested in clinical trials involving tens of thousands of people to make sure they meet safety standards and protect adults of different races, ethnicities, and ages. vaccine. General: COVID-19 Vaccine Consent Form (letter size) (Updated May 2021) Fillable (pdf) COVID-19 Vaccine Consent Form (legal size) (Updated May 2021) Fillable (pdf) Everyone who is immunized must complete this consent form. If my child has previously had a severe allergic reaction to a vaccine or injectable medicatio n, my child and I agree that my child will remain in the observation area for 30 minutes after receiving the vaccine. Also, check with your child’s health care provider to see if they or their affiliated hospital is offering vaccination. All Vaccine Recipients Must Sign The COVID-19 Vaccination Consent Form. Can you give me a second dose? Pfizer COVID-19 Vaccine Now Available to Louisiana Residents Ages 12 and Above Prior to this announcement, the Pfizer vaccine was recommended and authorized for people no younger than 16 years of age. A: COVID-19 vaccines are safe and effective. Timing is dependent on how much vaccine we receive and when vaccine shipments arrive. HOUSTON - Harris County Public Health has announced children ages 12-15 can receive the Pfizer COVID-19 vaccine starting on Thursday. Please check the box below, then sign and date. After obtaining an appointment and before arriving at any of the state-owned COVID-19 vaccination sites, the Florida Department of Health is advised to print and fill out a screening and consent form prior to the appointment, if possible. In the past 2 weeks, have you been in contact with anyone who tested positive for COVID-19? In the United States, one COVID-19 vaccine has been granted authorization from the U.S. Food and Drug Administration (FDA) for use in people age 16 and older – the Pfizer vaccine. General. The state is working on the allocation of vaccines manufactured by Pfizer / BioNTech … Signature of Patient/Parent/Guardian: ... Ultra-cold COVID-19 Vaccine Pfizer-BioNTech Frozen COVID-19 Vaccine Moderna Refrigerated COVID-19 Vaccine AstraZeneca Janssen Novavax-Matrix-M1 6. An emancipated minor may consent for him/herself. Benefits of Getting a COVID-19 Vaccine While the COVID-19 vaccines are being developed as quickly as possible, routine processes and procedures remain in place to ensure the safety of any vaccine that is authorized or approved for use. KISD will continue to support employees who have shown interest in receiving the vaccine. First Dose - Click Here To Schedule Your Appointment. Pfizer-BioNTech COVID-19 Vaccine EUA Fact Sheet for Recipients and Caregivers (fda.gov) Page 1 of 2 Pfizer-BioNTech COVID-19 Vaccine Effective Date: 12/13/2020 COVID-19 VACCINE SCREENING AND CONSENT FORM Pfizer-BioNTech COVID-19 Vaccine SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT) Name: Last: First: Middle Initial: COVID-19 Vaccine - First Dose Consent Form COVID-19 Vaccine - Second Dose Consent Form. COVID-19. In L.A. County, an estimated half-a-million adolescents are now able to get the free Pfizer shots. Persons younger than 18 years must have parental or guardian consent given by a legally authorized representative (parent or guardian). PATIENT CONSENT FORM FOR EMERGENCY USE AUTHORIZATION (EUA) OF . THE PFIZER-BIONTECH COVID-19 VACCINE TO PREVENT CORONAVIRUS . About COVID-19 vaccination People who have a COVID-19 vaccination have a much lower chance of getting sick from COVID-19. ... Timelines for designated groups to receive the COVID-19 vaccine may change. Download Adult Consent Form . Read this Fact Sheet for information about the Pfizer-BioNTech COVID-19 Vaccine. The forms can be read and printed by clicking the links below. Put the day/time and place your e-signature. By signing this consent, I am agreeing that Authorized Use. The minimum age to receive a COVID-19 vaccine is 16. Canada’s COVID-19 Immunization Plan: Saving Lives and Livelihoods; Planning Guidance for Administration of COVID-19 Vaccine; COVID-19 PFIZER Vaccine Screening and Consent Form. I confirm I understand the risks and benefits of the COVID-19 vaccine being offered. The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. Consent for Pfizer BioNtech COVID-19 Vaccine for Children (May 19, 2021) SHA 0096 COVID-19 Vaccine Consent - Substitute Decision Maker (February 16, 2021) NOTE: This consent is for those persons 18 years and older who are unable to understand or sign for their own medical services and have a legal substitute decision-maker. I reviewed this consent form and have read and understand the “Fact Sheet for Recipients and Caregivers” about the potential risks and benefits of the Pfizer Vaccine. Furthermore, I agree: patinet is at least 16 years of age; or (c) authorized to consent for vaccinatino for the patinet named above. The FDA has made the COVID-19 vaccine available under an emergency use authorization (EUA). Do you have an allergy to the Pfizer COVID-19 vaccine or any of its components (polyethylene glycol [PEG], potassium chloride, monobasic potassium phosphate, dibasic sodium phosphate dihydrate, sucrose), or an allergy to polysorbate? Screening Questions Yes No Unsure . I confirm I have received and read the COVID-19 vaccine information leaflet. Report an adverse event related to the Pfizer COVID-19 vaccine here. COVID-19 Vaccine Information Effective Monday, April 5, 2021 all Florida residents shall be eligible to receive any COVID-19 vaccine as prescribed by the Food and Drug Administration. Ph: 817-284-1489 OFFSITE EVENT - 16 Years Old + May 15, Pfizer COVID-19 Vaccine Consent Form. Consent form for COVID-19 vaccination Before completing this form make sure you have read the information sheet on the vaccine you will be receiving, either COVID-19 Vaccine AstraZeneca or Comirnaty (Pfizer). Use of this form is one option. I have been given access to the “FACT SHEET FOR RECIPIENTS AND CAREGIVERS” for the COVID-19 vaccine. You can search for a site offering the Pfizer vaccine on the NYC COVID-19 Vaccine Finder. • I confirm that I have the legal authority to consent to this immunization. Consent Form and Vaccine Recipient Emergency Use of Authorization Fact Sheet (EUA). Minors between the ages of 12 – 17 years of age may receive the Pfizer vaccine at a county-run or state-supported sites but must be accompanied by a parent or guardian and bring with them a completed parental consent form. There is no FDA- approved vaccine to prevent COVID-19 at this time. COVID-19 Vaccine- Pre-Screening Assessment Tool for Health Care Providers: A pre-screening tool for health care providers administering any COVID-19 vaccine. COVID-19 Vaccine Consent Form Page 1 of 2 Pfizer-BioNTech COVID-19 Vaccine Effective Date: 1/04/2021 . (tick) 4. • A component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures • Polysorbate • A previous dose of COVID-19 vaccine 4 Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? Guidelines. The CDC approved the FDA’s expansion on May 12th. Consent form for COVID-19 vaccination - While it is not mandatory to obtain written consent, practices will need a way to ensure patients have the relevant information prior to receiving the vaccine and document informed consent. section 1: information about you (please print) last name utsa id (abc123) After dilution, one vial contains 6 doses of 0.3 mL. COVID-19 Vaccine Consent Form CONSENT FORM – Pfizer-BioNTech COVID-19 Vaccine Version 1.1 – December 14, 2020 Last Name First Name Identification (e.g., health card number) Home Phone Mobile Phone Email Address Primary Care Clinician (Family Physician or Nurse Practitioner) Street Address City Province Postal Code Date of Birth ☐ I consent to the release of my Covid-19 vaccine status, including any supporting documentation, to all. Vaccine Brand (Pfizer or Moderna): _____ To obtain the vaccine in Florida, individuals 12-17 years of age must be accompanied by a guardian and complete the COVID-19 vaccine and screening consent form. Consent form for COVID-19 vaccination Before completing this form make sure you have read the information sheet on the vaccine you will be receiving, either COVID-19 Vaccine AstraZeneca or Comirnaty (Pfizer). Both Pfizer and Moderna COVID-19 vaccines require a two-dose administration and both doses must be received at the same vaccine provider. A: Experts recommend you get the same vaccine for both doses. Pfizer-BioNTech COVID-19 Vaccine . SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT) Name: Last: First: Middle Initial: Students and COVID-19. Fill in the empty areas; involved parties names, places of residence and phone numbers etc. Assessment, consent and PSD form for use with COVID-19 mRNA vaccine BNT162b2 (Pfizer/BioNTech) at the PCN Designated Site Vaccine recipient details First Name Date of birth Surname Home address Postcode Phone/Mobile Email address Please read and answer the following questions carefully. I GIVE CONSENT to the NAME OF ORGANIZATION CONDUCTING CLINIC and its staff for my child named at the top of this form to be vaccinated with this vaccine. Please review the forms below before your vaccination appointment. Recipient’s Information: There is no COVID-19 virus in the vaccine. Step-by-step guide to the COVID-19 vaccination clinic journey 1. Fact Sheet for Recipients and Caregivers . ... COVID-19 VACCINE CONSENT FORM. Documents in other languages. Parent or guardian will be required to show ID and complete and sign a consent form on-site for their child to be vaccinated. COVID-19 VACCINE SCREENING AND CONSENT FORM Pfizer BioNTech COVID-19 Vaccine COVID19-1E (12-20) SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT) Last Name First Name Middle Name Date of Birth Age in Years: Sex (Gender assigned at birth) Month Day Year Male Female Race American Indian or Alaska Native Asian Section 1: Information about Child to Receive Vaccine (please print) STUDENT’S NAME (Last) (First) (M.I.) Help accessing your vaccination record: Pfizer Vaccine to prevent COVID -19 in individuals 12 years of age and older. I am an adult who can legally consent for the person named below to receive the COVID-19 vaccine. National coronavirus and COVID-19 vaccine helpline. Minor Consent. Harris County Judge Lina Hidalgo said anyone 12 years and older can get their Pfizer COVID-19 vaccine between noon and 9 p.m. daily at NRG Park. The _☐Pfizer ☐Moderna_ COVID-19 vaccine has been authorized by the Food and Drug Administration under an Emergency Use Authorization, or EUA, based on advice from the Secretary of Health and Human Services in response to the ongoing COVID-19 Pandemic. The form must be filled out completely and signed by a parent or guardian. To learn more about risks, benefits, and side effects of the Pfizer vaccine, read the U.S. Food and Drug Administration’s . 7. For those 12-17, they must have a parent or guardian sign the vaccine consent form. Consent for the Pfizer-BioNTech COVID-19 Vaccine I am consenting to the administration of the Pfizer-BioNTech COVID-19 vaccine. The Johnson & Johnson vaccine is a single-dose vaccine.
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