Information on the risks and benefits of the Pfizer BioNTech COVID-19 Vaccine
The Pfizer-BioNTech COVID-19 Vaccine may prevent the person vaccinated from getting COVID-19. There is no U.S. Food and Drug Administration (FDA)- approved vaccine to prevent COVID-19. However, the FDA has authorized the emergency use of the vaccine to prevent COVID-19 vaccine in individuals 16 years of aeand older under the Emergency USe Authorization (EUA). The Pfizer BioNTech COVID-19 Vaccine is administered as a 2 dose series, 3 weeks apart, into the muscle. The vaccine may not protect everyone. Side effects that have been reported with the Pfizer-BioNTech COVID-19 vaccine include injeciton site pain,tiredness, headache, muscle pain, chills, joint pain, fever, ineciotn site swelling, injeciton site readness, nausea, feeling unwell, and swollen lymph nodes. There is a remote chane that Pfizer-BioNTech COVID-19 vaccine could cause a severe allergeic reaction. A severe allergic reaction would usually occure within a few minutes to one hour after getting a dose of the Pfizer -BioNtech Covid -19 vaccine. For this reason, a vaccine provider may ask the person receiving the vaccine to stay at the place where they recieve the vaccine for monitoring after vaccination. Signs of severe allergic reaction include difficulty breathing, swelling, of the face and throat, a fast heartbeat, and a bad rash all over the body. The Pfizer-BioNTech COVID-19 Vaccine "Fact Sheet for Recipients and Caregivers" is available at https://www.fda.gov/media/144414/download.
Consent for Minor's Vaccination: I have reviewed the information on risks and benefits of the Pfizer-BioNTech COVID-19 vaccine above and understand the risks and benefits. In providing my consent below, I agree that: I have reviewed this consent form, and I understand that the "Fact Sheet for risks and benefits of the Pfizer-BioNTech COVID-19 vaccine. I have legal authority to consent to have the child named above vaccinated with the Pfizer-BioNTech COVID-19 Vaccine. I understand I am required to be present at the first vaccination appintment, but not required to accompany the child named above to their follow-up vaccination appointment and that, by giving my consent below, the child will receive the Pfizer-BioNTech COVID-19 Vaccine whether or not I am present at the vaccination appointment. If I have health insurance that covers the child named above. I give permission for my insurance company to be billed for the costs of administering the Pfizer-COVID-19 Vaccine. The goverment is paying for the Pfizer-BioNTech COVID-19 Vaccine itself, and I will ot be billed for that portion of the cost of my immunization. I understand that as required by state law, all immunizations will be reported to the appropriate state immunization registration system.
I GIVE CONSENT for the child named at the top of this form to get vaccinated with the Pfizer-BioNTech COVID-19 Vaccine and have reviewed and agree to the information included in this form. (If this consent is not signed, dated and returned, the child will not be vaccinated.)