I declare that I or my child: 1. Is not currently sick with a fever, active respiratory infection or other moderate/severe illness and will notify the office immediately if these symptoms occur at any point prior to the appointment. Has have not received monoclonal antibodies or convalescent plasma for treatment of COVID-19 within the past ninety (90) days. 3. Is not allergic to the following ingredients in the COVID-19 vaccine: mRNA, pids4-hydroxybutyl)azanediyl)bis(hexane-6,1-diyl)bis(2-hexyldecanoate), 2[(polyethylene glycol)-2000]-N, ,N-ditetradecylacetamide, 1, 2-Distearoyl-sn-glycero-3-phosphocholine,and cholesterol), potassium chloride, monobasic potassium phosphate, sodium chloride, dibasic sodium phosphate dihydrate and sucrose. I understand that if I or my child have any of the above conditions, I or my child could be at increased risk of having a negative reaction or problem from the vaccine. I further declare that if I or my child have any of the conditions listed directly below, I have had the opportunity to speak with my or my child's primary care provider and am making an informed decision to receive the vaccine or to have my child receive the vaccine: Pregnant, attempting to become pregnant or breastfeeding; Have a bleeding disorder or are on a blood thinner; 3. Are immunocompromised or aretaking a medication that affects the immune system (such as cortisone, prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease or psoriasis; HIV/AIDS, cancer, leukemia, ankylosing spondylitis or radiation treatments toWAIT in the designated clinic location for 15 minutes after receiving the vaccine. If I or my child have previously had a severe allergic reaction to a vaccine or agree injectable medication, I agree to WAIT in the clinic location for 30 minutes after receiving the vaccine. I agree to seek immediate help for any concerns of a reaction.
I understandthat the COVID-19 vaccine is a two-part vaccine series. By signing this consent, I am agreeing that I or my child will receive the first and second part of the vaccine series as scheduled.
I understand that the common risks associated with the COVID-19 vaccine include but are not limited to pain, redness or swelling at the site of injection, tiredness, headache, musclepain,chills,jointpain, fever, nausea, feeling unwell or swollen lymph nodes (lymphadenopathy I understand that the vaccine may cause a severe allergic reaction which include(difficulty breathing, swelling of the face and throat, a fast heartbeat, a rash all over the body, dizziness and/or weakness I understand that these may not anaphylaxis side betheeffectsof the COVID-19 vaccine as the vaccine is still being studied in clinical trials. I also understand that it is not possible to predict all possible side effects or all complications which could be associated with the vaccine. I understand that the long-term side effects or complications of this vaccine are not known at this time.
I understand that the vaccination is being given by Center for Pediatric & Adolescent Medicine The owner and/or operator of this site, their affiliates, officers, directors, employeesandagents expressly disclaim any responsibility for the vaccination. My consent is given in light of this knowledge, and in consideration of Center for Pediatric & Adolescent Medicine giving the COVID-19 vaccine. I, for myself and my heirs, administrators, trustees, executors, assigns and successors in interest do hereby agree to release and hold harmless Center for Pediatric & Adolescent Medicine its subsidiaries, divisions, affiliates, successors, assigns, officers, trustees, employees, volunteers and agents from and against any and all demands, damages, losses, costs, expenses, obligations, liabilities, claims, actions and cause of action (whether any of which is groundless or otherwise) of any nature whatsoever (including, without limitation, reasonable attorney's fees and court costs) by reason of or resulting, in any way, from any and all acts, accidents, events, occurances, omissions and the like related to, or arising out of, directly or indirectly, my receipt of this COVID-19 vaccine. Center for Pediatric & Adolescent Medicine makes no warrenties, express or implied, including but not limited to, implied warranties of merchantability or fitness for a particular purpose regarding the vaccine or its effectiveness. I acknowledge receipt of Center for Pediatric & Adolescent Medicine Notice of Privacy Practices.