Pfizer COVID-19 Vaccine Screening Form & Consent

Please correct the errors described below.

Please answer the following questions about your child (or yourself if you are the one receiving the COVID-19 vaccine). If you answer “yes” to any questions, it does not necessarily mean you should not be vaccinated.

I have read the Omaha Children's Clinic Pfizer COVID-19 Vaccine Handout and have been provided with the most current EAU Pfizer Vaccine Fact Sheet and have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of the COVID-19 vaccine, including side effects and request the vaccine be given to me or my child.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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