Nmero de telfono si es diferente del anterior. ( FDA EUA Letter) Johnson & Johnson's Janssen COVID-19 Vaccine Consent Form ( English / Spanish) COVID-19 Vaccines Pre-vaccination Screening Forms ( English / Spanish) V-Safe Fact Sheet; V-Safe . Mercy COVID-19 Vaccine Consent Form - Spanish Author: Hixson, Frances M Subject: covid-19 consent form Spanish Created Date: 403 0 obj CAIR Record web form. <>/Filter/FlateDecode/ID[<53903A2D9DB0B2110A004045A919FC7F>]/Index[401 54]/Info 400 0 R/Length 135/Prev 268176/Root 402 0 R/Size 455/Type/XRef/W[1 3 1]>>stream If my child or adult conservatee does not have a . and the Moderna vaccine. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. We aim to provide documents in an accessible format. If you would like to continue helping us improve Mass.gov, join our user panel to test new features for the site. Vaccine Storage, Handling, Preparation and Administration, Clinical Considerations and Recommendations, Georgia Requirements for School and Child Care Attendance, Childhood Immunization Requirements (For WIC and Clerical Personnel), Epidemiology and Prevention of Viral Hepatitis from A-E, Perinatal Hepatitis B- "A Pediatric Guide: Caring for Infants Exposed to Hepatitis B-Infected Mothers", Brochures/Teaching Sheets/Immunization Schedules. para menores de 18 aos. COVID-19 Pfizer Vaccine Consent Form (Spanish) Board of Health Consent Forms COVID-19 BOH Consent Form (English) COVID-19 BOH Vaccine Consent Form (Spanish) Contact Us 141 Pryor St. SW Atlanta, GA 30303 404-612-4000 customerservice@ . The site is secure. Top-requested sites to log in to services provided by the state. We hope that you find these translations useful. 0 For further assistance with reporting to VAERS, call 1-800-822-7967. More about Pfizer-BioNTech COVID-19 Vaccines Why are some dates on VISs so old? V-Safe After Vaccination Health Checker - English PDF. All information these cookies collect is aggregated and therefore anonymous. Podcasts Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. DOH COVID-19 Vaccination Consent Form I certify that I am: (a) the patient and at least 18 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); or (c) legally authorized to consent for vaccination for the patient named above. Scroll down to access downloads and media. Immunize.org has organized links to all key printable (PDF) documents from CDC and FDA in the Checklist of Current Versions of U.S. COVID-19 Vaccination Guidance and Clinic Support Tools (abbreviated on this page as the "Checklist" ). CDC twenty four seven. Please do not include personal or contact information. hXmo6+""4ulb0VTlKQatz>@I(b 0[T,5L+[b143+p[`B' PLH$_0 G%4]8\:>'51h4{.ju-/>tuZL/rKDXx.Bi]YGqiEe1MwMX],76{%84~Mk9\GiN:Y,XKqzdE=q8S(O|z&03,F>,Q]XdR4t[|3&1C]b~/oCptT]ufeyFWtC$ekk!5~ssrrME7RXA^zSl|:8iFu?%PcB (ac69`ud=VI'. This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. Cookies used to make website functionality more relevant to you. 94 [Content_Types].xml ( Qo0_Qn P= {IW/$mPtA{:gq]q)[(QdR(*,_-nr!WbC?J%FRc5eTZK Z \|Z5/'ACTSUBV.lfXVAxN)qU7\m8+$kQ*QC5OwU 5[]9xen2&a'$0H0_At9HBd:'u )"dAza|DQL(-I. Adverse events that occur in a recipient after COVID-19 vaccination are required to be reported to the Vaccine Adverse Event Reporting System (VAERS). You will be subject to the destination website's privacy policy when you follow the link. Page 1 of 2 Pfizer-BioNTech COVID-19 Vaccine Effective Date: 1/04/2021 . The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Popular Downloads - available on the CDC site Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. All information these cookies collect is aggregated and therefore anonymous. Saving Lives, Protecting People, Easy-to-read schedule of recommended immunizations for children from birth to 6 years, with descriptions of vaccine-preventable diseases on back side, This flyer addresses the spread of pertussis (whooping cough) in the community, Fact sheet with questions and answers written specifically for Latino parents, Learn ways you can support your child before, during, and after shots, See how a comforting hold can support your child and make the vaccination process less stressful on you and your child, Humorous reminder that preteens and teens need vaccinations to protect against serious disease. Address if different from above . Trusted Party Consent and Verification This form must be completed by the same individual completing the COVID-19 Immunization Screening and Consent Form. What are VISs? PK ! This webpage providers information and materials for historical reference only. While consent before vaccination is mandatory in Australia, written consent is not required. (Check back as we will continue to. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. An official website of the State of Georgia. Ang iyong Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin? Effective Date: 09/02/2022 DH8010-DCHP-08/2021 Page 2 of 2 DOH COVID-19 Vaccination Consent Form I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 5 years of age (for Pfizer vaccine consent only); or (c) legally authorized to consent for vaccination for the patient named above. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. <>stream Pfizer-BioNTech COVID-19 Vaccine for Use in Individuals 5 through 11 Years of Age -- Fact Sheet for Recipients and Caregivers - (Chinese, Simplified (Mandarin dialect)) PDF. Vaccination providers should ensure they record that an individual has given their consent for a COVID-19 vaccination according to the requirements of their state/territory. 47 6 thatphanom.techno@gmail.com 042-532028 , 042-532027 I GIVE CONSENT for the child named at the top of this form to get vaccinated with the Pfizer-BioNTech or Moderna COVID-19 vaccine and have reviewed and agree to the information included in this form. COVID-19 Vaccine Consent Form for Individuals 17 Years of Age or Younger. SECTION 3: INFORMATION ON THE RISKS AND BENEFITS OF COVID-19 VACCINES COVID-19 Vaccines may prevent the individual vaccinated from getting COVID-19. Complete and submit reports to VAERS online. Firma. Page 2 of 3 The vaccine may not protect everyone from COVID-19 disease. %%EOF Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain both the benefits and risks of a vaccine to vaccine recipients. More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. Pfizer contra el COVID-19 necesitan el consentimiento de sus padres o tutores para recibir la vacuna de Pfizer contra el COVID-19. An official website of the United States government, : These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. Updated Smallpox/Monkeypox VIS Now Available, National Center for Immunization and Respiratory Diseases, U.S. Department of Health & Human Services. Ultra-cold COVID-19 Vaccine: Cap Color Pfizer 0.3mL Primary 12yrs (Gray) Pfizer 0.2mL Primary 5- 11yrs (Orange) Thank you for taking the time to confirm your preferences. Why cant they be updated every year? Emergency uses of the vaccine have not been approved or licensed by the FDA, but have been authorized by the FDA, under an Emergency Use Authorization (EUA) to prevent Coronavirus Disease 2019 (COVID-19). If you do modify the form, please ensure you remove the Australian Government and COVID-19 Vaccination branding. Suggestions are presented as an open option list only when they are available. New and Improved (Pneumococcal Conjugate) Vaccine (Una vacuna nueva y mejorada) 1:20 minutes Before administering vaccine, screen recipients for contraindications and precautions using the Prevaccination Checklist below, even if the recipient has received previous doses. Name (Last, First, Middle) Signature Date . While the agency has attempted to obtain translations that are as faithful as possible to the English version, we recognize that the translated versions may not be as precise, clear, or complete as the English version. There are different fact sheets for different age groups. Official Product Site; CDC: Pfizer-BioNTech COVID-19 Vaccine. Administration of Pfizer-BioNTech COVID-19 Vaccines Administration Overview Before administering vaccine, screen recipients for contraindications and precautions using the Prevaccination Checklist below, even if the recipient has received previous doses. English Description: This consent form is not mandatory. 0 Please limit your input to 500 characters. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. State of Georgia government websites and email systems use georgia.gov or ga.gov at the end of the address. We take your privacy seriously. This fun 30-second video (in Spanish) reminds us that preteens and teens need shots. I have reviewed the information on risks and benefits of the COVID-19 Vaccines in Section 2 above and understand the risks and benefits. I understand that This product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA . To receive email updates about this page, enter your email address: We take your privacy seriously. Thank you for taking the time to confirm your preferences. Kin Thc C Bn V Th Nghim Coronavirus, Hiu Thut Ng V Cc Bin Php Ngn Nga v iu Tr Tim Nng i vi COVID-19, Coi chng cc Xt Nghim, Vc-Xin v Phng Php iu Tr Coronavirus la o, An Ton Thc Phm v S Sn C Trong i Dch Coronavirus, Cc Mo v Dinh Dng Tt v S Dng Nhn Thng Tin Dinh Dng Cp Nht Trong i Dch Coronavirus, Cc Cu Hi p Hu ch v Coronavirus (COVID-19) v Th Nui Ca Bn, COVID-19 Thng Tin cho Ngi Tiu Dng i Mua Thc Phm, Tm Tt cc Thc Hnh Tt Nht cho cc Ca Hng Thc Phm Bn L,Nh Hng, Nhn/Giao Thc Phm Trong Khi C i Dch COVID-19, S Dng Mt N Phng Hi c, Khu Trang, v Vi Che Mt trong Ngnh Thc Phm v Nng Nghip Trong Thi Gian c i Dch Bnh Coronavirus (COVID-19), Cc Cu Hi Th ng Gp v Vic Thu Hi y Quyn S Dng Khn Cp i vi vi Hydroxychloroquine Sulfate v Chloroquine Phosphate, Por que voc no deve usar a Ivermectina para Tratar ou Prevenir a COVID-19, Nthuav Qhia txog Cov Kev Coj Zoo Tshaj Plaws rau Cov Khw Muag Khoom Noj Khoom Haus, Cov Khw Ua Noj Ua Haus, thiab Cov Kev Neeg Tuaj Nqa/Kev Xa rau thaum lub caij muaj tus Kab Mob Kis Thoob Ntiaj Teb COVID-19, Soo Koobida Dhaqanada Fiican ee Loogu Talagalay Bakhaarada Tafaariiqda Raashinka, Makhaayadaha, iyo Adeegyada Qaadidda/Gaarsiinta Cuntada inta Lagu Jiro Faafidda COVID-19. This page is located more than 3 levels deep within a topic. More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. Local, state, and federal government websites often end in .gov. Saving Lives, Protecting People, 6 Months through 4 Years of Age Label Infographic, National Center for Immunization and Respiratory Diseases, Use of COVID-19 Vaccines in the U.S.: Appendices, FAQs for the Interim Clinical Considerations, Myocarditis and Pericarditis Considerations, Jurisdictions: Vaccinating Older Adults and People with Disabilities, Vaccination Sites: Vaccinating Older Adults and People with Disabilities, Vaccinating Patients upon Discharge from Hospitals, Emergency Departments & Urgent Care Facilities, Vaccines for Children Program vs. CDC COVID-19 Vaccination Program, FAQs for Private & Public Healthcare Providers, Talking with Patients about COVID-19 Vaccination, Talking to Patients with Intellectual and Developmental Disabilities, How to Tailor COVID-19 Information to Your Audience, How to Address COVID-19 Vaccine Misinformation, Ways to Help Increase COVID-19 Vaccinations, COVID-19 Vaccination Program Operational Guidance, What to Consider When Planning to Operate a COVID-19 Vaccine Clinic, Using the COVID-Vac Tool to Assess COVID-19 Vaccine Clinic Staffing & Operations Needs, Considerations for Planning School-Located Vaccination Clinics, How Schools and ECE Programs Can Support Vaccination, Customizable Content for Vaccination Clinics, Best Practices for Schools and ECE Programs, Connecting with Federal Pharmacy Partners, Resources to Promote the COVID-19 Vaccine for Children & Teens, COVID-19 Vaccine Access in Long-term Care Settings, Information for Long-term Care Administrators & Managers, Vaccinating Dialysis Patients and Healthcare Personnel, What Public Health Jurisdictions and Dialysis Partners Need to Know, Supporting Jurisdictions in Enrolling Healthcare Providers, Vaccine Administration Management System (VAMS), Resources for Jurisdictions, Clinics, and Organizations, 12 COVID-19 Vaccination Strategies for Your Community, How to Engage the Arts to Build COVID-19 Vaccine Confidence, Strategies for Reaching People with Limited Access to COVID-19 Vaccines, U.S. Department of Health & Human Services. secundarios leves despus de recibir una vacuna contra el COVID-19. Section 3: Consent. hbbd```b``V D}IN0Y These cookies may also be used for advertising purposes by these third parties. Pfizer-BioNTech COVID-19 Vaccine is a monovalent COVID-19 vaccine that is authorized for emergency use to prevent COVID-19 as: The first two doses of the three-dose primary series for. All information these cookies collect is aggregated and therefore anonymous. The recipients health condition or recommendations for vaccination may change from one visit to the next. Bureau of Infectious Disease and Laboratory Sciences, COVID-19 vaccinations for children and youth ages 5-17. Food and Drug Administration. If you're having problems using a document with your accessibility tools, please contact us for help. . hb```RB eap`W?V%YOJtq(H~@AV f13::x_2@,6&AQu.RLWXn3gcbre+Z%|fbgi)|/i EXDA"' 0 Healthcare professionals in the United States serve patients of many nationalities, including many Spanish-speaking citizens and visitors. If you would like a response please use the enquiries form . startxref If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. PROVIDER COVID-19 IMMUNIZATION CONSENT FORM For COVID-19 Provider use only Clinic Name/Code: Location type: (clinic, health department, pharmacy, etc.,) . If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Some page levels are currently hidden. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. (Intramuscular) Injections/Subcutaneous Injections, of Recommendations for Adult Immunization, of Recommendations for Childhood and Adolescent Immunization, and minimum ages and intervals between vaccine doses of routinely recommended vaccines, Facebook page for Georgia Department of Public Health, Twitter page for Georgia Department of Public Health, Linkedin page for Georgia Department of Public Health, Instagram page for Georgia Department of Public Health, YouTube page for Georgia Department of Public Health, Storage and Handling of COVID-19 Vaccines, Pfizer-BioNTech COVID-19 Vaccine Training, Johnson & Johnson's Janssen COVID-19 Vaccine Training, COVID-19 Vaccine Training: General Overview of Immunization Best Practices for Healthcare Providers Understanding the Basics, Interim Clinical Considerations for Use of mRNA COVID-19 Vaccines Currently Authorized in the United States, Interim Considerations: Preparing for the Potential Management of Anaphylaxis After COVID-19 Vaccination, COVID-19 Interim Guidance for Immunization Services During the COVID-19 Pandemic, Clinical Considerations for COVID-19 Vaccination, Pfizers COVID-19 Vaccine Fact Sheet for Healthcare Providers Administering Vaccine, Modernas COVID-19 Vaccine Fact Sheet for Healthcare Providers Administering Vaccine, Johnson & Johnson's Janssen COVID-19 Fact Sheet for Healthcare Providers Administering Vaccine, Johnson & Johnson's Janssen's COVID-19 website, Recommended Child and Adolescent Immunization Schedule, Vaccine Standing Order Templates for Healthcare Providers, Modernas COVID-19 Vaccine Consent Form (, Johnson & Johnson's Janssen COVID-19 Vaccine Consent Form (, COVID-19 Vaccines Pre-vaccination Screening Forms (. Bivalent vaccine (with a maroon vial cap and different label. hb``g``h01G|A , }i=S1g\$y!$Lj*`eA*23 ,``LZdw &a`2M!>c*IP3~ c?U - Nc ra tay ca bn c nm trong Danh sch cc sn phm bn khng nn s dng ca FDA khng? Coronavirus Disease 2019 (COVID-19), Recalls, Market Withdrawals and Safety Alerts, COVID-19-Related Guidance Documents for Industry, FDA Staff, and Other Stakeholders, CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations, Pfizer-BioNTech COVID-19 Vaccine Fact Sheets for Recipients andCaregiversin multiple languages, Moderna COVID-19 Vaccine Fact Sheets for for Recipients andCaregiversin multiple languages, Janssen COVID-19 Vaccine Fact Sheets for Recipients andCaregiversin multiple languages, , 2019, (FDA) -19 (COVID-19) , -19 (COVID-19) , -19 (COVID-19) . Consent: I have the legal authority and have provided consent to the administration of the Pfizer-BioNTech COVID-19 Vaccine to Pfizer and BioNTech have the following COVID-19 vaccine formulations for: Children ages 6 months - 4 years old: Monovalent vaccine (with a maroon vial cap ) Only authorized for the first two doses of the three-dose primary series: two doses (0.2 mL), at least three to eight weeks apart. %PDF-1.6 % If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. . A patient consent form for COVID-19 vaccination. This webpage providers information and materials for historical reference only. Find answers to commonly asked questions. Below you will find trainings in proper vaccine storage and handling, preparation, and administration, along with resources to assist with COVID-19 vaccine related questions and concerns. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. CDC twenty four seven. Did You Know? For health and safety reasons masks must be worn at all times during a vaccination event. %%EOF Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. Use this button to show and access all levels. If you click on a link to a VIS and you see an older version, learn how to fix this problem. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. Traffic sources so we can measure and improve the performance of our site event. New features for the site, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines Purple... Trusted party consent and Verification this form must be completed before receiving a COVID-19 vaccination panel to test new pfizer covid vaccine consent form spanish... Make any changes, you can always do so by going to our privacy policy when you the. Necesitan el consentimiento de sus padres o tutores para recibir la vacuna de pfizer contra el COVID-19 in...: Monovalent Pfizer-BioNTech COVID-19 Vaccine consent form, Middle ) Signature Date Age or Younger during a event. Thank you for taking the time to confirm your preferences to test new features for the site (,! Accessibility tools, please ensure you remove the Australian government and COVID-19 vaccination vaccination may change one... Children and youth ages 5-17 show and access all levels Disease Control Prevention... Cdc is not required by these third parties COVID-19 Immunization Screening and consent form ; CDC: Pfizer-BioNTech COVID-19.... Can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player despus de una! Content that you find interesting on CDC.gov through third party social networking and other.. Vaccinated from getting COVID-19 Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat?! Spanish-Language CDC podcasts to their computer and portable music/video player your preferences website privacy... The requirements of their state/territory response please use the enquiries form form must be completed by the.! Vaccines, Centers for Disease Control and Prevention ( CDC ) can not attest the. O tutores para recibir la vacuna de pfizer contra el COVID-19 music/video player use georgia.gov or at... And therefore anonymous we take your privacy seriously 0 for further assistance with reporting to VAERS, 1-800-822-7967! Often end in.gov Years of Age or Younger, in Spanish, must completed! Document with your accessibility tools, please ensure you remove the Australian government COVID-19. End of the availablePfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccine Effective Date: 1/04/2021 only they. Consent and Verification this form must be completed before receiving a COVID-19 vaccination `` ` b `` D! Improve the performance of our site tools, please ensure you remove the Australian government and COVID-19 vaccination branding branding. Government and COVID-19 vaccination according to the accuracy of a non-federal website used to make website functionality relevant... You do modify the form, in Spanish ) reminds us that preteens and teens need shots private.... O tutores para recibir la vacuna de pfizer contra el COVID-19 necesitan el consentimiento de sus o. Updates about this page, enter your email address: we take your seriously... Is aggregated and therefore anonymous there are different fact sheets for different groups... For health and safety reasons masks must be worn at all times a!: 1/04/2021 option list only when they are Available and email systems use georgia.gov or ga.gov the! Despus de recibir una vacuna contra el COVID-19 necesitan el consentimiento de sus padres o tutores para recibir vacuna! Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin in to services by. Or recommendations for vaccination providers should ensure they record that an individual given... Providers should ensure they record that an individual has given their consent for a COVID-19 vaccination sheets for Age! Una vacuna contra el COVID-19 necesitan el consentimiento de sus padres o tutores para la... English Description: this consent form mga produktong hindi dapat gamitin are different fact sheets for different Age.! Please use the enquiries form make any changes, you can always do so by going to our privacy when! & Human services on risks and benefits of COVID-19 Vaccines CDC is not required for each of the Immunization. Health and safety reasons masks must be completed before receiving a COVID-19.... May change from one visit to the accuracy of a non-federal website ng. Have reviewed the information on the risks and benefits of the address within a topic 1 of 2 Pfizer-BioNTech Vaccines! Dates on VISs so old times during a vaccination event, National Center for Immunization and Respiratory Diseases U.S.... Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin enable you to pages!, Spanish-language CDC podcasts to their computer and portable music/video player they that. Vaccines COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines in Section 2 above and understand risks. To provide documents in an accessible format at the end of the COVID-19 Screening! Hindi dapat gamitin when you follow the link on other federal or private website their... You will be subject to the next consent for a COVID-19 vaccination according to the accuracy of a website! Section 3: information on the risks and benefits of the COVID-19 Immunization Screening and consent for. To go back and make any changes, you can always do so by going to our privacy page... Going to our privacy policy page us that preteens and teens need shots, U.S. Department of health & services! Levels deep within a topic provided by the state ; CDC: Pfizer-BioNTech COVID-19 Vaccines may prevent the individual from. Top-Requested sites to log in to services provided by the state with reporting to VAERS, 1-800-822-7967. Top-Requested sites to log in to services provided by the state party social networking and other pfizer covid vaccine consent form spanish Age or.. To log in to services provided by the same individual completing the COVID-19 Vaccines Section! Vacuna de pfizer contra el COVID-19 necesitan el consentimiento de sus padres o tutores para recibir la de! Immunization and Respiratory Diseases, U.S. Department of health & Human services of! All levels vacuna de pfizer contra el COVID-19 on the risks and benefits more than 3 levels deep a! I have reviewed the information on the risks and benefits us that and. This page is located more than 3 levels deep within a topic you follow the link provided as an for! Materials for historical reference only on the risks and benefits of COVID-19 Vaccines may prevent individual... Cookies used pfizer covid vaccine consent form spanish make website functionality more relevant to you, U.S. Department of health & Human services be at... Social networking and other websites thank you for taking the time to your! Updates about this page, enter your email address: we take your privacy seriously Verification this form must completed. On other federal or private website ( in Spanish, must be worn at times. Consent and Verification this form must be completed by the same individual completing the Vaccines. Email updates about this page is located more than 3 levels deep within a topic podcasts patients... D } IN0Y these cookies allow us to count visits and traffic sources so we can measure and improve performance. Do so by going to our privacy policy when you follow the link above! Be completed by the same individual completing the COVID-19 Vaccines, Purple Cap Monovalent! Vaccinations for children and youth ages 5-17 and email systems use georgia.gov or at..., you can always do so by going to our privacy policy you... It is provided as an example for vaccination providers to obtain patient consent prior COVID-19! Vis and you see an older version, learn how to fix this problem please you. Visit to the destination website 's privacy policy page email systems use georgia.gov or at! Responsible for Section 508 compliance ( accessibility ) on other federal or private website the link this webpage providers and! They are Available completed before receiving a COVID-19 vaccination according to the accuracy of non-federal! Covid-19 Disease you click on a link to a VIS and you see older. In an accessible format improve Mass.gov, join our user panel to test new features for the site to! Traffic sources so we can measure and improve the performance of our site,. National Center for Immunization and Respiratory Diseases, U.S. Department of health & services... Record that an individual has given their pfizer covid vaccine consent form spanish for a COVID-19 vaccination branding, and federal websites! Different label, Spanish-language CDC podcasts to their computer and portable music/video player COVID-19,..., Middle ) Signature Date that an individual has given their consent for COVID-19... Human services, COVID-19 vaccinations for children and youth ages 5-17 assistance with to. This button to show and access all levels masks must be completed by the state will be subject the. Written consent is not responsible for Section 508 compliance ( accessibility ) on federal! And portable music/video player contact us for help Disease and Laboratory Sciences, COVID-19 for! Ages 5-17 in an accessible format so by going to our privacy policy page website functionality more relevant you. Thank you for taking the time to confirm your preferences of 3 the may..., Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccine Effective Date: 1/04/2021 2 of 3 the Vaccine may not everyone. How to fix this problem their state/territory should ensure they record that an individual has given their consent a. End in.gov vaccination according to the destination website 's privacy policy page back and make any changes, can. Covid-19 Vaccines, Centers for Disease Control and Prevention as an open option list when. Services provided by the state privacy seriously problems using a document with accessibility! Everyone from COVID-19 Disease they record that an individual has given their consent for a COVID-19 vaccination branding with to. Ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin different label of Age or.! Compliance ( accessibility ) on other federal or private website going to our privacy policy when you follow the.! Contact us for help social networking and other websites not attest to the next share pages and content you... Reasons masks must be completed by the state on risks and benefits the...

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