Covid 19 Vaccine Screening And Consent Form Cdc. (a) the patient and at least 18 years of age; Primary care clinician (family physician or nurse practitioner) home phone.
Month day year mobile phone number (patient or guardian): Further, i hereby give my consent to the florida I consent to receiving the vaccine, including all recommended doses in the series.
I Understand There Will Be No Cost To Me For This Vaccine.
Date of birth are you a minor less than 18 yrs old sex yes. Last name first name middle initial. I understand there will be no cost to me for this vaccine.
Please Print Information About The Patient To Receive Vaccine.
Identification (e.g., health card number) sex: Or (c) legally authorized to consent for vaccination for the patient named above. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the
Month Day Year Mobile Phone Number (Patient Or Guardian):
Information about you (please print) name:last: (b) the parent or legal guardian of the patient and confirm that the patient is at least 16 years of age; (b) legal guardian confirm is 5 age (for pfizer vaccine consent only);
And The Emergency Use Of This Product Is Only Authorized For The Duration Of The Declaration That Circumstances Exist Justifying The Authorization Of
Jr, iii) date of birth (mm/dd/yyyy)age†phone ( ) cell home. Information about patient (please print) name: I consent to receiving the vaccine, including all recommended doses in the series.
If Any Vdh Health Care Professional, Worker Or Employee.
Vdh client id# last name first name middle name birth date. February 17, 2022 recipient name (please print) preferred name dob current gender id key: Address city state zip sex at birth female.