Safeway Covid Vaccine Consent Form. If you have any questions please ask a pharmacist. (a) the patient and at least 18 years of age;
That i have the legal authority to consent to this immunization. Consent by legal decision maker 2. Printed name of person giving consent daytime telephone number alternate telephone number
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If You Are Being Inoculated By Cvs, We’ve Included That Form Below.
With this consent and release. (b) the parent or legal guardian of the patient and confirm that the patient is at least 16 years of age; Or (c) a person authorized to consent on behalf of the patient where the patient is not otherwise competent or unable to consent
Vaccine Administration Record (Var)—Informed Consent For Vaccination Section C I Certify That I Am:
The pfizer covid vaccine for kids under 12 is a lower dose given twice, 21 days apart. Complete only one of the following two options: I have had the opportunity to ask questions about the vaccine(s) which were answered to my satisfaction.
By My Signature Below, I Consent To The Administration Of The Vaccine(S) By A Pharmacist Or A Supervised Student Pharmacist Or Technician, Or Other Authorized Person, Where Permitted By Law Or State/Federal Guidance, Employed Or Contracted By Albertsons Companies Or One Of Its Affiliated Pharmacies And To Be Contacted At The Number Provided
Client parent legal decision maker other _____ (on behalf of client) b. For ages 18 years and older: 4) i will immediately alert the pharmacist of any medical conditions.
Informed Consent For Immunization With Inactivated Vaccine.
All forms are printable and downloadable. 4) i will immediately alert the pharmacist of any medical conditions which may adversely affect my personal health or effectiveness of the vaccine. Inactivated flu vaccine quadrivalent (qiv) is a standard dose flu shot that protects against four strains of the flu virus.
The Letter Templates Can Be Adapted To Suit The Needs.
Am of legal age and authorized to execute this consent form or i am the parent/guardian of the minor patient. More than 95% of children receiving the mmr vaccine will be protected from the three diseases throughout their lives. Printed name of person giving consent daytime telephone number alternate telephone number