LOCATION: Natick High School Cafeteria (15 West St, Natick MA)
TIME: June 13th(8 AM- 4 PM)
Elligible group: Everyone 12 years and older. Please read this entirely and fill out the required details below.
Janssen (approved for ages 18+, 1 dose): 500 doses
Moderna (approved for ages 18+, 2 seperate doses): 500 doses
Pfizer (approved for ages 12+, 2 seperate doses): 2000 doses
For vaccine recipients:The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.
I hereby give my consent to the V-Care Pharmacy licensed healthcare professional to administer the vaccine(s) I have requested above. I acknowledge that I have been provided with the Vaccine Information Statement(s) (VIS) corresponding to the vaccine(s) that I am receiving. I have read the provided information and I understand the benefits and risks of vaccines. Furthermore, I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccines and I voluntarily assume full responsibility for any reactions that may result. I have had a chance to ask questions and that such questions were answered to my satisfaction about the vaccine (s) I requested. I understand that I should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored for any potential adverse reactions. I understand that V-Care Pharmacy may be required to disclose my health information to the physician responsible for the immunization protocol. In addition, I understand the purpose and benefit of my state's immunization registry (MIIS) and give consent to V-Care Pharmacy to disclose my vaccination information to the state registry for purposes of public health reporting as required by my state's law. I acknowledge that I may opt out of MIIS reporting via the state-approved opt-out form provided to me by V-Care Pharmacy if requested. I understand that the FDA has authorized the emergency use of the Pfizer, Moderna and Janssen COVID-19 Vaccines, which are not FDA-approved vaccines. I have received a copy of "Fact Sheet for Recipients and Caregivers" or I can go to https://www.modernatx.com/covid19vaccine-eua (Moderna) or https://www.fda.gov/media/144414/download (Pfizer) or https://www.janssenlabels.com/emergency-use-authorization/Janssen+COVID-19+Vaccine-HCP-fact-sheet.pdf (Janssen) for access to information about the vaccines. I understand that if this is my first dose, I will need a follow-up appointment for the second dose of the vaccine.
CONSENT FOR MINOR’S VACCINATION:
I have reviewed the information on risks and benefits of the Pfizer-BioNTech COVID-19 Vaccine and understand the risks and benefits. In providing my consent below, I agree that:
You are not eligible for this clinic.
This clinic is for patients 12+ who have not had any other vaccine within the past 14 days. Please call us with any questions.