COVID Vaccine Consent Form _______________________________ ___________________________ __________________________ ___________ _________________________ ___________________________ ______________________________________________________________________________________________________________ _______________________ __________________________________ ___________________________________ _____________________________________________ _________________________________________________ Race: White Black/African American Asian Native Hawaiian/Pacific Islander American Indian/Alaskan Native Other Hispanic: Y N By Signing and initialing below, I confirm have received information regarding the following COVID-19 Vaccination: First Name Middle Name Last Name Suffix Date of Birth SS# Gender: M F Address County Phone Number Email Mother’s First Name Mother’s Maiden Name I have received the FDA Fact Sheet for Patients and Parents/Caregivers, which includes information on potential risks, benefits, purpose, side effects, dosing methods, and alternative treatment choices for the Vaccine. I have been informed that the Vaccine is an unapproved vaccine that may prevent COVID-19. There is no FDA-approved vaccine to prevent COVID- 19 but the Vaccine has received Emergency Use Authorization (EAU) from the FDA. Initials: I hereby give my consent to the Abilene-Taylor County Public Health District (ATCPHD) to administer the Vaccine I have requested above. I understand the risk and benefits associated with the Vaccine being administered and have received, read and/or had explained to me the written information on the Vaccine I have elected to receive. I have had the opportunity to ask questions that were answered to my satisfaction. As with all medical treatment, there is no guarantee that I will not experience an adverse reaction from the Vaccine. I understand that the information contained on this form may be shared with the state or federal immunization registries and will remain confidential and will not be released except as permitted or required by law. I have read and understood the HIPAA form explaining my privacy rights, ATCPHD’s duty to protect health information that identifies you and how ATCPHD may use or disclose health information that identifies you without your written permission. I hereby acknowledge receipt of the ATCPHD’s “Notice of Privacy Practices” form. Furthermore, I agree to remain for approximate 15-30 minutes after administration for observation. Signature: ___________________________________________________ Date: _______________________ Printed Name: ________________________________________________ Initials: Street City State Zip PLEASE PRINT For Provider Use Only 1st Dose / 2nd Dose Insured / Uninsured