Covid Form | MartinCountyHospital

COVID-19 Vaccine Release Form

Formulario de Consentimiento para la Vacuna contra el COVID-19

Date Fecha:

Recipient Name Nombre de Recipiente:

Date of Birth Fecha de Nacimiento:

Address Dirección:

City Ciudad:

State Estado:

Phone Numero de Teléfono:

Email Correo Electrónico:

Emergency Contact & Phone: Contacto de Emergencia / Numero de Teléfono:

Race Raza:

Ethnicity Etnia:

By checking this box, you acknowledge that you will arrive between 10:30 AM - 1:00 PM on the day of the injection and understand that the 2nd injection will be 4 weeks later. We will not hold injections for anyone. First come, First serve.

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

Date Fecha

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.