COVID-19 Vaccine Consent For Non-Burgess Patients

Please correct the errors described below.

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 reviewed this consent form and have read and understand the “Fact Sheet for Recipients and Caregivers” about the potential risks and benefits of both the Pfizer Vaccine and the Moderna Vaccine.
  • I have the legal authority to consent to have myself or the child named above vaccinated with the Pfizer Vaccine or the Moderna Vaccine.
  • I understand I am not required to accompany the child named above to the vaccination appointment and, by giving my consent below, the child will receive the Pfizer Vaccine or the Moderna Vaccine whether or not I am present at the vaccination appointment.
  • I understand that as required by state law (Health and Safety Code, § 120440), all immunizations will be reported to the California Immunization Registry (CAIR2). I understand the information in the child's CAIR2 record will be shared with the local health department and State Department of Public Health, shall be treated as confidential medical information, and shall be used only to share with each other or as allowed by law. I may refuse to allow the information to be further shared and can request the CAIR2 record be locked by visiting the Request to Lock My CAIR Record web form.

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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