Section 1: Information about the person to receive a COVID-19 Vaccine
Section 2: Information on the risks and benefits of the COVID-19 Vaccine (Pfizer and Moderna Vaccine).
The U.S. Food and Drug Administration (FDA) has authorized emergency use of the Pfizer and Moderna Vaccines to prevent COVID-19 in individuals ages 6 months and older. The FDA has not yet approved licensure of the vaccine to prevent COVID-19 for any individuals under the age of 16. Please read the Fact Sheets for Recipients and Caregivers that are posted on the US FDA website to learn more about risks, benefits, and side effects of the Pfizer vaccine and the Moderna vaccine. There are different fact sheets for different age groups.
Section 3: Consent, either for myself or my child under 18 years old
I have reviewed the information on risks and benefits of the COVID-19 Vaccines in Section 2 above and understand the risks and benefits. I agree that:
I GIVE CONSENT for the person named at the top of this form to get vaccinated with the Pfizer or Moderna COVID-19 Vaccine and have reviewed and agree to the information included on this form.
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