Consent (Signing this consent form you attest to the following):
• The minor patient is 5 years of age or older
• I have the legal authority to consent to the administration of the Pfizer-BioNTech COVID-19 Vaccine to the minor patient
• I understand that the U.S. Food and Drug Administration (“FDA”) has authorized the emergency use of the Pfizer-BioNTech COVID-19 Vaccine, which is not an FDA-approved vaccine.
• I have been provided access to and read the Pfizer-BioNTech COVID-19 Vaccine EUA Fact Sheet for Recipients and Caregivers (“Fact Sheet”). (Read the Fact Sheet at https://www.fda.gov/media/144414/download
• I understand the known and potential risks and benefits of Pfizer-BioNTech COVID-19 Vaccine and the extent to which such risks and benefits are unknown.
• I understand that I have the option to accept or refuse Pfizer-BioNTech COVID-19 Vaccine on behalf of the minor patient.
• I understand that the Pfizer-BioNTech COVID-19 Vaccine is a two-part vaccine series.
• I consent to and authorize all medically necessary treatment in the rare event that the minor patient has a reaction to the vaccine, including but not limited to itching, swelling, fainting, anaphylaxis, and other reactions.
• The minor patient and I agree that the minor patient will remain in the observation area for the required time period following vaccine dose administration.
• I consent to the administration of two separate doses of Pfizer-BioNTech COVID-19 Vaccine spaced approximately three weeks apart to the minor patient. practice