By signing this form, I declare that the information I have provided above are true and correct to the best of my knowledge. I understand the risks involved in having the COVID-19 Vaccination. I understand that a COVID-19 vaccine requires two doses, with at least 20 days apart from each dose or one dose for the Janssen. In this regard, I shall ensure to comply with the scheduled dates for vaccination. I have been given an opportunity to ask questions in relation to COVID-19 and the immunization, which answers were given to me to my satisfaction I understand that it is my free prerogative to refuse or receive administration of the vaccine and all the consequences of the risks over this matter. In any case, I request that the COVID-19 vaccination be given to me. It is my responsibility to secure or determine whether my insurance policy covers the administration of the vaccine. In case not, I shall be responsible to pay for the costs in cash. Finally, I authorize the release of my health information as needed for public health purposes, including for reportorial purposes for vaccine registry.