Consent for Pfizer-BioNTech COVID-19 Vaccine
Care Alliance Health Center provides healthcare services to individuals. After you have read this form, and have had the opportunity to ask questions, please sign and date it to indicate your agreement and consent to receive the Pfizer-BioNTech COVID-19 vaccine. If at any time you do not understand any section of this form, please notify a staff member who is available to read this form and answer questions. Service will not be provided to anyone who changes or alters the terms or language of this consent form.
I have read or have had read to me the information in the Fact Sheet for Recipients and Caregivers: Emergency Use Authorization (EUA) of the Pfizer-BioNTech COVID0-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine being administered and ask that the vaccine be given to me or to the person named below for whom I am authorized to make this request. I hereby give my consent to Care Alliance Health Center to bill my insurance for the vaccine, if applicable. I authorize the release of this record to the Ohio Department of Health Immunization Program. I hereby acknowledge that I have received and read the Care Alliance Health Center's Notice Regarding the Use and Disclosure of Protected Health Information (Notice of Privacy Practices).