COVID-19 VACCINATION CONSENT AND RELEASE
I, the undersigned guardian, understand that my dependent is being offered the opportunity to receive a COVID-19 Vaccine (referred to in this document as “the Vaccine”). I understand that the Vaccine is either Pfizer, depending on what is available at this time. I have been informed prior to administration of the actual vaccine of which vaccine my dependent is receiving and have been given a copy of The Fact Sheet for Recipients and Caregivers (“the Fact Sheet”) that provides information about the Vaccine, including but not limited to the currently known possible risks and side effects of the Vaccine. I have reviewed the Fact Sheet and have had the opportunity to ask questions and have them answered by a healthcare professional at the vaccine location.
I understand and agree that my dependent must wait at the vaccination location for at least 15 minutes after receiving the Vaccine. If my dependent has previously had a severe allergic reaction to a vaccine or injectable medication, I understand and agree that he/she must wait at the vaccination location for at least 30 minutes after receiving the Vaccine.
I understand that the common risks associated with the Vaccine include but are not limited to pain, redness or swelling at the site of injection, tiredness, headache, muscle pain, chills, joint pain, fever, nausea, feeling unwell or swollen lymph nodes (lymphadenopathy). I understand that the Vaccine may cause a severe allergic reaction which can include anaphylaxis (difficulty breathing, swelling of the face and throat, a fast heartbeat, a rash all over the body, dizziness and/or weakness and potentially death). I understand that these may not be all the side effects of the 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 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 Vaccine is being administered by Public Health Management Corporation and all of its controlled and affiliated entities and their respective employees, officers, directors, trustees and agents (collectively, “PHMC”). I understand that PHMC expressly disclaims any responsibility for the Vaccine or the vaccination. My consent is given in light of this knowledge, and in consideration of PHMC administering the Vaccine to me. I, for myself and my heirs, administrators, trustees, executors, assigns and successors in interest do hereby agree to release and hold harmless PHMC (as defined above) from and against any and all demands, damages, losses, costs, expenses, obligations, liabilities, claims, actions and cause of action of any nature whatsoever (including, without limitation, attorney’s fees and court costs) by reason of or resulting in any way from any and all acts, accidents, events, occurrences, omissions and the like related to, or arising out of, directly or indirectly, my receipt of the Vaccine or PHMC’s administration of the Vaccine. PHMC makes no warranties, 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 am the legal guardian of First Name* Last Name*(dependent name), and voluntarily and willingly consent to him/her receiving the Vaccine. I desire and authorize PHMC and its personnel to administer the Vaccine. I have read and understand the foregoing document and, by my signature below, agree to its terms and intend to be legally bound.