DPH-GEORGIA DEPARTMENT OF PUBLIC HEALTH

DPH-GEORGIA DEPARTMENT OF PUBLIC HEALTH

COVID-19 VACCINE INFORMATION AND CONSENT FORM
Name

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Date
Age
Address

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EMERGENCY CONTACT

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Member ID/Policy Number
Please answer the health questions below
YesNoDon't Know
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*If yes, vaccine product and the date administered:
YesNoDon't Know
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Access and review Emergency Use Authorizations (EUA) using the links below or at NCHD52.org/covidvaccine.
I have been given a copy and have read the Emergency Use Authorization (EUA) and reviewed the FDA Fact Sheet for Recipients and Caregivers for the COVID-19 vaccine product I will be administered (choose one of the following): blanks Pfizer (age 16 & over); blank Moderna (age 18 and over); blanks Janssen (age 18 and over). I have had the chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine indicated and ask that it be given to me or the person named for whom I am authorized to make this request.
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First NameLast Name
My signature acknowledges that I was advised to remain on site for 15 minutes after receiving the vaccine. Those with previous anaphylactic reactions should say for 30 minutes.

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Parent or Parent/Guardian Signature
Date

MonthDayYear
Date
FOR ADMINISTRATIVE USE ONLY
Pfizer https://www.fda.gov/media/144414/downloadModerna https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdfJanssen https://www.janssenlabels.com/emergency-use-authorization/Janssen+COVID-19+Vaccine-HCP-fact-sheet.pdf
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DPH-GEORGIA DEPARTMENT OF PUBLIC HEALTH

Please answer the health questions below

Access and review Emergency Use Authorizations (EUA) using the links below or at NCHD52.org/covidvaccine.

FOR ADMINISTRATIVE USE ONLY