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  • Lititz Apothecary (6 Mon-4 Years) COVID19 Vaccine Consent Form

  • Location: Lititz Apothecary (100 East Main St. Lititz PA 17543)

    Rules to receive the COVID Vaccine

    THIS FORM IS ONLY FOR PFIZER AGES 3-4 YEAR OLDS. While Vaccine is approved for 6 months to 4 years old, we can only administer vaccines to ages 3-4 year olds at the pharmacy. 

    UPDATE (6-18-2022): FDA Authorizes & CDC/ACIP expands eligibility for COVID-19 vaccines to infants and children 6 months and older

    Added guidance for a three dose primary series of the Pfizer-BioNTech COVID-19 vaccine (3 microgram each dose (maroon cap and label) for infants and children 6 months through 4 years of age) (two doses separated by 21 days (3 weeks), followed by a third dose at least 8 weeks after the second dose).

    - Once you hit “Submit” you will be prompted to print a form and bring the form with you to your appointment. The form will be emailed to you at the email address you provided and can be printed from your email later, if desired. It is very important that you bring this form with you to the event as it is required for vaccination. 

    - There will be a PDF that will be provided on the "Thank You" email please PRINT and provide this to the intake team.

    - We ask that Only one parent per child should be present inside the facility

    - Please arrive no earlier than 5 minutes prior to your appointment time. This is to avoid proper workflow and improve efficiency

    - Please bring ID of the parent the child is with along with all medical insurance information. 

    - Please reframe from calling the pharmacy as we are inundated with questions. If you can email your questions to info@Lititzrx.com we will get back to you.  

    - Dress appropriately for the vaccine in order to allow your upper arm to be easily accessed.

    We need your cooperation in order to successfully administer Covid-19 vaccines to as many people as possible. Non-compliance to the above instructions significantly affects our ability to work efficiently.

     

     

     

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  • Consent (Signing this consent form you attest to the following):

    • The minor patient is 3 years through 4 years old

    • 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 three-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.

     

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