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Covid-19 Vaccine Screening And Consent Form Pfizer

Covid-19 Vaccine Screening And Consent Form Pfizer. I hereby certify that the foregoing answers to the health questions are true and complete to the best of my knowledge. Or (c) legally authorized to consent for vaccination for the patient named above.

Covid19 Screening & Consent Form Lakeview Denture from clinicforms.co

* use of this form is optional. (b) the legal guardian of the patient and confirm that the patient is at least 12 years of age (for pfizer vaccine consent only); Or (c) legally authorized to consent for vaccination for the patient named above.

I Hereby Certify That The Foregoing Answers To The Health Questions Are True And Complete To The Best Of My Knowledge.

(b) the legal guardian of the patient and confirm that the patient is at least 12 years of age (for pfizer vaccine consent only); (a) the patient and at least 18 years of age; I consent to receiving the vaccine, including all recommended doses in the series.

Age In Years Sex (Gender.

Information about minor child to receive vaccine (please print) * use of this form is optional. Or (c) legally authorized to consent for vaccination for the patient named above.

Information About You (Please Print) Name:

Information about minor child to receive vaccine (please print) minor’s name (last) (first) (m.i.) minor’s date of birth (mm/dd/year): (b) the parent or legal guardian of the patient and confirm that the patient is at least 16 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 12 years of age (for pfizer vaccine consent only);

Page 1 Of 2 (Please Turn Over)

Information about you (please print) last name utsa id (abc123) (a) the patient and at least 18 years of age; I understand that a “yes” response to any of the health questions

(A) The Patient And At Least 18 Years Of Age;

Or (c) legally authorized to consent for vaccination for the patient named above. Page 1 of 2 oph form _____; This page was intentionally left blank.

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