I request the vaccine to be given to me or to the person named above, a minor for whom I represent and am authorized to sign this consent form. I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet), a copy of which was provided with this consent form (online or in print]. - have had a chance to ask questions that were answered to my satisfaction agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving myvaccine to ensure that no immediate adverse reactions occur. understand that will be receiving the vaccination at no cost to me. If insured, authorize the pharmacy to bil my insurance on my behalf for the the immunization understanding that will not incur any costs. If uninsured, I attest that do not have any insurance, including, but not limited to Medicare, Medicaid, or any other private or government-funded benefit plan.If uninsured, authorize the pharmacy to use my social security number, state identification number, or driver's license number to bil the United States Health Resources & Services Administration's COVID-19 Program on my behalf for the immunization understanding that will not incur any costs I understand that at this time, some COVID- 19 vaccines require 2 doses given 21-28 days apart dependent on the manufacturer.