Vaccine Consent Form

Emergency Use Authorization I understand the benefits and risks of the vaccine or medical treatment as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided. Emergency Use Authorization. The FDA (or other regulatory body) has made this product available under an emergency use authorization (EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency. This product has not undergone the same type of review as an FDA-approved or cleared product. However, the decision to make the product available is based on the totality of scientific evidence available, showing that known and potential benefits outweigh the known and potential risks. Consent I have read, or had explained to me, the information sheet about the vaccination or medical treatment. I understand that if my vaccine requires multiple doses, I will need to complete all doses as prescribed to receive full protection. Further, I understand that additional doses (boosters) may be recommended for certain populations or based on individual circumstances, such as age, medical conditions, or risk of exposure, to increase protection. I have had a chance to ask questions, which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination or medical treatment as described. I request that the vaccination or medical treatment be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I authorize the release of all information needed (including but not limited to medical records, copies of claims, and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable registries. I have had a chance to ask questions that were answered to my satisfaction. I request the treatment to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.

I understand that some vaccines may require multiple doses given at specific intervals, depending on the manufacturer. If this is my second or subsequent dose, I will bring my vaccination card with me to be completed.

I agree to remain in the vaccination area for a recommended period of time after receiving my vaccine to monitor for any immediate adverse reactions, as advised by the vaccine administrator.

I understand that there will be no direct cost to me for receiving this vaccine. I acknowledge that any payments or benefits related to the administration of the vaccine will be assigned and transferred to the administering provider, including those from my health plan, Medicare, or other third parties responsible for my medical care.