Covid-19 Vaccine Screening And Consent Form In Spanish. If any vdh health care professional, worker or employee. I understand that any monies or benefits for administering the
I understand that any monies or benefits for administering the Last name first name middle name (optional) mother’s maiden name (optional) date of birth (mm/dd/yyyy) gender address no address available insurance information Patient information (staff only) appointment id:
Table of Contents
Last Name First Name Middle Name (Optional) Mother’s Maiden Name (Optional) Date Of Birth (Mm/Dd/Yyyy) Gender Address No Address Available Insurance Information
Date of birth are you a minor less than 18 yrs old sex yes. Form reviewed by date adapted with appreciation from the immunization action coalition (iac) screening checklists. I understand there will be no cost to me for this vaccine.
I Consent To Receiving The Vaccine, Including All Recommended Doses In The Series.
This page was intentionally left blank. Information about you (please print) last name Spanish | simplified chinese | nepalese | russian | swahili | vietnamese;
I Understand That If My Vaccine Requires Two
Additional resources doh screening and consent form (english) (pdf, 205kb) (a) the patient and at least 18 years of age; I understand that any monies or benefits for administering the
Information About Minor Child To Receive Vaccine (Please Print) Minor’s Name (Last) (First) (M.i.) Minor’s Date Of Birth (Mm/Dd/Year):
Or (c) legally authorized to consent for vaccination for the patient named above. Patient information (staff only) appointment id: If any vdh health care professional, worker or employee.
(B) The Legal Guardian Of The Patient And Confirm That The Patient Is At Least 12 Years Of Age (For Pfizer Vaccine Consent Only);
Before you proceed, please read the following: Vdh client id# last name first name middle name birth date. Last name first name middle initial.