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Expert health care, without leaving home! Consent form for COVID-19 vaccination Before you fill out this form, make sure you read the information sheet on the vaccine you will be getting: Vaxzevria (AstraZeneca) , Comirnaty (Pfizer) or Spikevax (Moderna). MEDICAL HISTORY: Complete the following questions for individual receiving vaccine. Are you currently on quarantine due to an exposure to COVID -19? Rev. I have had the chance to ask questions that were answered to my satisfaction. I give consent to the Health Department and its authorized staff for my child named at the top of this form to receive the COVID-19 vaccine. SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT) Last Name . Further, I understand that a booster dose of COVID-19 vaccine may be recommended at least 2 months following the first dose of Janssen vaccine or at least 6 months following the second dose of Pfizer-BioNTech or Moderna COVID-19 vaccine if I am a member of a certain population (e.g., 65 years or older, 18 years old or older and a resident of Consent I have read, or had explained to me, the information sheet about the COVID‐19 vaccination. COVID-19 Vaccines. At least two months after the patient’s first dose. 2. COVID-19 VACCINATION CONSENT FORM For Snohomish Health District vaccination sites Screening for Vaccine Eligibility Have you ever received a dose of COVID-19 vaccine? If Yes – allow to schedule If No –“Defer vaccination until improvement in symptoms for ... (Pfizer, Moderna and Johnson and Johnson) ; and the emergency use of this product is only authorized for the duration of the declaration that On this date, Moderna Spikevax ® transitioned to an authorization under the Food and Drug Regulations.

About COVID-19 vaccination. COVID-19 Vaccine Consent Form. NSP Vaccine Administration Consent Form- Rev.
However, if a minor was inadvertently vaccinated with Moderna as a first dose, the U.S. Centers for Disease Control and Prevention recommends they still receive the second dose of Moderna on time to complete the series. If you have any questions about your individual risk for Moderna COVID-19 vaccine www.modernatx.com. Know before you go. In addition, a consent form signed by the parent/legal guardian must be presented at the time of … See Fact Sheet for Recipients and Caregivers beginning X . (Photo by Andrew Milligan - Pool / Getty Images) (Pool, 2020 Getty Images) Pfizer COVID-19 BOOSTER Vaccine INFORMATION AND CONSENT FORM Guest Account ... Moderna 1st dose _____ 2nd dose _____ J&J 1st ... For any reaction to a previous COVID-19 vaccination, I have been advised to stay for 30 minutes. Pfizer-BioNTech. COVID-19 Vaccination Consent Form Last Name (Please print) ... dose of either Pfizer-BioNTech or Moderna COVID-19 vaccine at least 28 days after they got their second COVID-19 dose. If yes, which … Birth registrars: DO NOT use this form. 08/2021) Use this form to register your child, aged 17 and younger, in ImmTrac2. There is no FDA-approved vaccine to … Consent form for COVID-19 vaccination. COVID-19 VACCINE CONSENT WHITE – KECK MEDICINE OF USC COPY – EMPOLYEE/PATIENT 314/363-5620 (8-21) ... 15 years of age and Moderna and Janssen for individuals 18 years of age and older. I, , being the parent, guardian or legal representative . To obtain a copy of the form, click here. I also understand that it is not possible to predict all possible side effects or complications which could be associated with the vaccine. People who have a COVID-19 vaccination have a much lower chance of getting sick from COVID-19. The Moderna COVID‑19 Vaccine has not been approved or licensed by the US Food and Drug Administration (FDA), but has been authorized for emergency use by FDA, under an Emergency Use Authorization (EUA), to prevent Coronavirus Disease 2019 (COVID‑19) for … In clinical trials, approximately 15,400 individuals 18 years of age and older have received at least 1 dose of the Moderna Vaccines for children 5 to 11 years old are also available at the County’s Sports and Learning Complex, pediatricians’ offices, … USD 259 COVID-19 VACCINE CLINIC QUESTIONNAIRE AND CONSENT FORM DEMOGRAPHIC INFORMATION ... COVID-19 VACCINE CONSENT – Please print and sign/date in the area below. Page 2 of 2 I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet or Vaccine Information Statement (VIS-if available), a copy of which I was provided with this Consent Form. The Moderna and Johnson & Johnson vaccines can only be given to individuals age 18 years and older. DOOR COUNTY PUBLIC HEALTH COVID-19 2021 Door County Public Health COVID-19 VACCINATION Screening and Consent Form I have been given a copy and read or have had explained to me the information in the Emergency Use Authorization (EUA ) of the applicable COVID-19 Vaccine to prevent Coronavirus disease 2019. Release and Assignment of the COVID-19 Immunization Consent Form and Vaccine Recipient Emergency Use of Authorization Fact Sheet (EUA). The aim of the study was to determine if sufficient literature exists to require clinicians to disclose the specific risk that COVID-19 vaccines could worsen disease upon exposure to challenge or circulating virus. The Moderna COVID-19 vaccine will be available beginning in January for both Medicaid members and caregivers in a community care foster family home (CCFFH) or an expanded adult residential care home (E-ARCH). Please be advised that if you do not see any open dates for appointments, we are currently fully booked and will be opening more appointments on a weekly rolling basis, feel free to continue to check the website for availability. Booster doses may be a different product than the COVID-19 vaccine product used in the primary series (e.g., mix and match may be used for boosters. If your child is: 5 to 11: The Pfizer vaccine is the only one currently available under emergency use authorization for people 5 through 11 years of age. MEDICAL HISTORY: Complete the following questions for the individual receiving the vaccine. Last updated: 23 September 2021 . I understand the FDA has authorized emergency use of the VACCINE, which is not an FDA-approved vaccine. CONSENT 1. COVID-19 vaccine but require parental/guardian consent to receive the Pfizer COVID-19 vaccine. BRING THE PRINTED COPY TO YOUR VACCINE APPOINTMENT. Medicare payment rates for COVID-19 vaccine administration will be $28.39 to administer single-dose vaccines. ... doses of this vaccine, OR b.) Page 1 of 2 Moderna COVID-19 Vaccine Effective Date: 12/21/2020 COVID-19 VACCINE SCREENING AND CONSENT FORM Moderna COVID-19 Vaccine SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT) Name: Last: First: Middle Initial: Date of Birth: Month Day … Patient Signature _____ Date _____ decision to make the vaccine available is based on the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks. × COVID-19 Vaccine Clinic Update. COVID-19 Consent Form Please answer the following questions to determine if you are eligible for a vaccine. If YES refer to Pfizer website at www.PfizerMedInfo.com. CONSENT 1. : ... To read the Vaccine Recipient EUA Fact Sheet for Pfizer COVID-19 vaccine, Moderna COVID-19 vaccine, or Janssen COVID-19 A: The Pfizer-BioNTech and Moderna COVID-19 vaccines require two doses in order to get the most protection the vaccine has to offer. Moderna COVID-19 vaccine www.modernatx.com. If you have any questions please ask a pharmacist. If I am scheduling a booster shot for the COVID-19 vaccine, I attest that I am eligible for the booster in accordance with ACIP guidelines (Do not use until booster shot is authorized or approved). Providers who are enrolled as COVID-19 providers can contact LPHA and regional health systems to coordinate vaccine administration efforts. People 18 years and older who got Pfizer-BioNTech or Moderna COVID-19 vaccine as their primary series. If you answer “YES” you may not be able to receive the COVID-19 vaccine. A consent form is filled out for the Pfizer/BioNTech Covid-19 vaccine. The Pfizer COVID vaccine for kids under 12 is a lower dose given twice, 21 days apart. Date of Birth. Consent Forms for Minors and Adults: C-7 Immunization Registry (ImmTrac2) - Minor Consent Form (rev. (If you are under 18 you must have a parental consent to receive vaccine. Clinical Considerations for COVID-19 Vaccination; COVID-19 ACIP Vaccine Recommendations; Additional Educational Resources. The Pfizer COVID-19 Vaccine is over 90% effective at preventing COVID-19 in children ages 5 through 11 years. Please call your clinic to get the latest details. 2. Other Medicaid members will have the COVID-19 vaccine available to them at a later date. In addition, you can also report side effects to ModernaTX, Inc. at 1-866-MODERNA (1-866-663-3762). • You should wait at least 14 days after getting any other vaccine before you come to get the Moderna COVID-19 vaccine. back to top. DOH COVID-19 Vaccination Consent Form • I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 12 years of age (for Pfizer vaccine consent only); or (c) legally authorized to consent for vaccination for the patient named above. COVID-19 Vaccine Recipients Ages 18 and Older Are Eligible for Booster Shots. About COVID-19 vaccination I have been given a copy and have read, or have had explained to me, the information in the FACT SHEET for the COVID-19 vaccine (“VACCINE”). CDC has authorized booster doses of Pfizer-BioNTech for certain populations. The Moderna and Janssen (Johnson and Johnson) vaccines are authorized for persons age 18 and up. National protocol for … The Moderna COVID-19 Vaccine is administered as a primary series of two doses (0.5 mL each) 1 month apart to individuals 18 years of age or older. First Name Middle Name. Administration of Moderna COVID-19 vaccine with other vaccines. 4) I will immediately alert the pharmacist of any medical conditions which may adversely affect my personal health or effectiveness of the vaccine. DOH COVID-19 Vaccination Consent Form to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. I have been given a copy and have read, or have had explained to me, the information in the FACT SHEET for the COVID-19 vaccine (“VACCINE”). Many of our Well@Work clinics and OB-GYN clinics also offer COVID-19 vaccines. Janssen 2 Have you ever had abad reaction to vaccine including feeling dizzy or fainting? COVID-19 Vaccine Questionnaire Yes No 1 Do you feel sick today? All individuals must present a completed and signed consent form. The coronavirus ( COVID-19) vaccination consent form and letter templates are available in different software versions and can be downloaded. NSP Vaccine Administration Consent Form- Rev.

10/21 SECTION D: ATTESTATION AND CONSENT.. A COVID-19 vaccine may not be available for very young children until more studies are completed. Moderna Covid 19 Vaccine Information And Consent Form, Our best offers, tips and ideas to help you save money while staying home and staying safe. Note: Persons who have a contraindication to an mRNA COVID-19 vaccine (Moderna or Pfizer-BioNTech) may be able to receive the Janssen COVID-19 vaccine (see footnote). Have you ever received a dose of COVID-19 vaccine? PATIENT CONSENT/SIGNATURE (or parent/guardian if patient is age 17 or under) DATE OF CONSENT / / OFFICE USE ONLY VACCINE NAME COVID-19 LOT NUMBER ☒ EXPIRATION DATE DOSE SIZE Full (1.0) ☐ Half (0.5) MANUFACTURER ☐ Moderna (MOD) ☐ Johnson & Johnson (JNJ) ☐ Pfizer (PFR) ☐ Merck Moderna. Download a copy of the form, DOH Charlotte Consent Form ----- V-safe After Vaccination Health Checker Are you feeling well today, and do you have a bodily temperature below (100 F)? Information Sheet for this vaccine which explains the purpose, side effects, and possible complications of this vaccine and that after review of such documents, I consent to the administration of the COVID-19 Vaccine. I have had the chance to ask questions that were answered to my satisfaction. Patient, Parent/Legal Guardian, Person Acting in Loco Parentis-Printed Name Signature Date . Aims of the study: Patient comprehension is a critical part of meeting medical ethics standards of informed consent in study designs. Page 1 of 2 Moderna COVID-19 Vaccine Effective Date: 12/21/2020 COVID-19 VACCINE SCREENING AND CONSENT FORM Moderna COVID-19 Vaccine SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT) Name: Last: First: Middle Initial: Date of Birth: Month Day … The CDC recommends a third dose of Pfizer or Moderna COVID vaccines for people who are moderately to severely immunocompromised and have completed the initial series at least 28 days ago. People 18 years and older who got the Johnson & Johnson COVID-19 vaccine as their primary series should get a booster shot. 2. COVID-19 VACCINE SCREENING AND CONSENT FORM COVID-19 Vaccine – 12 and up. COVID-19 Vaccine for CCFFH & E-ARCH. A consent form is filled out for the Pfizer/BioNTech Covid-19 vaccine. Documents. A parent or guardian should complete the consent form for youths under 18.

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