Covid 19 Vaccine Screening And Consent Form Pfizer. Or (c) legally authorized to consent for vaccination for the patient named above. Information about you (please print) name:
Page 1 of 2 oph form _____; Or (c) legally authcrized to consent for vaccinatim f. * use of this form is optional.
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(A) The Patient And At Least 18 Years Of Age;
For minors who are 5 through 15 years of age, additionally, an adult caregiver should accompany the minor. I have had a chance to ask questions and they were answered to my satisfaction. (b) the parent or legal guardian of the patient and confirm that the patient is at least 16 years of age;
Information About You (Please Print) Last Name Utsa Id (Abc123)
I consent to receiving the vaccine, including all recommended doses in the series. I hereby give cmsent to flcrida of health (doh) or its to administer covid.19 vaccine. Or (c) authorized to consent for vaccination for the patient named above.
Or (C) Legally Authorized To Consent For Vaccination For The Patient Named Above.
(a) the patient and at least 18 years of age; Page 1 of 2 (please turn over) Page 1 of 2 oph form _____;
(A) The Patientand At Least18 Years Ofage;
Age in years sex (gender. I hereby certify that the foregoing answers to the health questions are true and complete to the best of my knowledge. This means that you have a weakened immune system that makes it harder for you to fight diseases.
(B) Legal Guardian Confirm Is 5 Age (For Pfizer Vaccine Consent Only);
Information about minor child to receive vaccine (please print) minor’s name (last) (first) (m.i.) minor’s date of birth (mm/dd/year): This fda approval and license is for use in individuals 16 years of (fcl pfizer vaccine consent only):