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 received your Primary Dose(s) of a COVID-19 vaccine, please tell us which vaccine(s) you received and the date(s) of vaccination.
If you have already received more than two (2) doses of a COVID-19 vaccine, please tell us which additional dose(s) you received, the vaccine(s), and the date(s) of vaccination.
Additional Dose received for High Risk Conditions
Booster Dose
Additional Booster Dose
I have read or had explained to me the Fact Sheet for Recipients and Caregivers 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.
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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COVID/VFC PIN
0 7 3 0
Provider Type
Private
Clinic Name
Highlands Integrative Pediatrics
Administered by:
For vaccine administration guidance, including: timing, dosing, site selection, needle length and gauge, and administration procedures, please reference your standing orders or the CDC’s Interim Clinical Considerations”.
https://covid19.colorado.gov/vaccine-providers
https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html
*Additional guidance from the FDA for 2nd booster dose is as follows:
*Additional Guidance for J &J Vaccine use:
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