Patients Insurance: _______________________Insurance Policy Number: _________________________

Policy holder First and Last name ______________________________DOB________________________

Emergency Use Authorization

The FDAhas made the COVID-19 vaccine available under an emergency use authorization (EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. This vaccine has not undergone the same type of review as an FDA-approved or cleared product. However, the FDA’s decision to make the vaccine available is based on the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks. The Janssen (Johnson & Johnson) COVID-19 vaccine is EUA authorized for those individuals 18 years old and older. The Novavax COVID-19 vaccine is EUA authorized for those individuals 12 years and older. Please note: FDA approved the Pfizer-BioNTech COVID-19 vaccine as a two-dose series in individuals 12 years of age and older; and approved the Moderna COVID-19 vaccine as a two-dose series in individuals 18 years of age and older. These vaccines continue to be available under an EUA for certain populations, including Pfizer-BioNTech COVID-19 vaccine for those individuals 6 months through 11 years old, and Moderna COVID-19 vaccine for individuals 6 months through 11 years old and for the administration of a third dose in the populations set forth in the consent section below.

Emergency Use Instruction

Emergency Use Instructions (EUIs) are issued by the CDC to provide information about emergency use of FDA-approved medical products that may not be included in or differ in some way from the information provided in the FDA-approved labeling (package insert). The COVID-19 vaccine by Pfizer-BioNTech is an FDA-approved COVID-19 vaccine (brand name Comirnaty, mRNA) to prevent COVID-19 in persons 12 years of age and older. CDC is issuing EUI to provide information about use of this vaccine as an additional primary dose in certain immunocompromised persons (12 years of age and older) and a booster dose in certain adults (18 years of age and older) who received certain non-FDA authorized or approved COVID-19 vaccine (e.g., certain vaccines available outside of the United States or from clinical trial participation).

Consent

I have read, or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if my vaccine requires two doses, I will need to be administered (given) two doses to be considered fully vaccinated. Further, I understand that a booster dose of COVID19 vaccine is recommended at least 2 months following the first dose of Janssen vaccine (if I am age 18 or older), or at least 5 months following the second dose of Pfizer-BioNTech (if I am age 5 or older) or Moderna COVID-19 vaccine (if I am age 18 or older), to increase my protection. I have had a chance to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described. I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health plan, Medicare or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.

☐ I acknowledge this information and consent to receiving the COVID-19 vaccine series.

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Print Name of Parent or Legal Guardian if applicable	Signature

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Phone Number (cell phone preferred)	Relationship to child