Please print neatly in capital letters. Please answer all questions as completely as possible.
Please complete ALL the information below as accurately as possible. If you are completing this form for your minor child, do not use nick-names or abbreviations, except where allowed. All information will be kept confidential.
If under 18 years of age please complete.
If you have already been vaccinated with a COVID-19 vaccine, please tell us which vaccine(s) was received, the number of doses, and the date(s) of vaccination
I have read or had explained to me the Emergency Use Authorization for the use of the COVID-19 vaccine and understand the benefits and risks to me or my child of receiving this vaccine. I have had a chance to ask questions, which were answered to my satisfaction. I hereby release this provider, its employees and its volunteers from any liability for any results which may occur from the administration of this vaccine.
STOP: DO NOT WRITE BELOW THIS LINE - FOR CLINIC STAFF ONLY
COVID/VFC PIN
0 7 3 0
Provider Type
Private
Clinic Name
Highlands Integrative Pediatrics
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