COVID-19 Vaccine Release Form

Formulario de Consentimiento para la Vacuna contra el COVID-19

COVID-19 VACCINE CONSENT (18 YEARS OF AGE AND OLDER) Consentimiento para la Vacuna contra el COVID-19

Please Initial Each Item Por favor firme sus iniciales:

I have been informed that the COVID-19 vaccine is an unapproved vaccine that has been authorized for use by the FDA under Emergency Use Authorization. Se me ha informado que la vacuna contra el COVID-19 es una vacuna no aprobada que ha sido autorizada para su uso por la FDA bajo la autorización de uso de emergencia

I have received the "Fact Sheet for Recipients and Caregivers." He recibido la “Hoja Informativa para Receptores y Proveedores de Cuidado”.

I understand that the COVID-19 vaccine is not mandatory. Entiendo que la vacuna contra el COVID-19 no es obligatoria.

I understand the significant known and potential risks and benefits of the COVID-19 vaccine, and the extent to which such risks and benefits are unknown. Entiendo los significantes riesgos y beneficios conocidos y posibles de la vacuna contra el COVID-19, y hasta qué punto se desconocen dichos riesgos y beneficios.

Signature Patient or Parent/Caregiver Date Fecha Firma del Paciente o de Padre o Tutor

Martin County Hospital District Mission Statement:  The mission of Martin County Hospital District is to set a new standard of excellence for medical care in our service area. By combining expert knowledge of our staff in their respective fields with compassionate care, we will strive to be the number one provider of primary care.

Pictures courtesy of Sandi Ramsey