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.

Thanks for choosing Martin County Hospital District. Should we have any questions we will contact you. Please be flexible with scheduling as this may change from time to time.