COVID-19 Vaccine Consent Form PDF COVID-19 Vaccine Consent Form.

Lifetime Immunization Record card

Printed by Immunization Action Coalition Saint Paul

IMMUNIZATION RECORD

IMMUNIZATION RECORD. Comprobante de Inmunización. Vaccine Reactions reacciones a la vacuna. VACCINE vacuna. DATE. GIVEN fecha de vacunación. DOCTOR OFFICE OR

Vaccine Administration Record for Adults

Sep 18 2566 BE How to Complete this Record. 1. For hepatitis B and meningococcal B vaccines

Vaccine Administration Record for Children and Teens

Sep 18 2566 BE RSV monoclonal antibody (mAb) is a passive immunization product

MISSOURI IMMUNIZATION RECORD

MISSOURI. IMMUNIZATION RECORD. OFFICIAL DOCUMENT. Retain this document as proof of immunizations. According to Missouri law your.

California Pre-Kindergarten and School Immunization Record

Record the date (month/day/year) of each dose the pupil has received even if the pupil has an exemption to one or more required vaccines. Any vaccine given

Childhood Immunization Record

Depending on where you live and your child's health your doctor may recommend other shots. Talk to your doctor about whether your child needs any of the

VACCINATION RECORD: EQUINE INFLUENZA AND EQUINE

Owner Name: Horse Name: This form may be used to for documenting Equine Influenza and Equine Herpes Virus (Rhinopneumonitis) vaccinations as defined in USEF

Student Immunization Record

If you do not have an immunization record for this student at home contact your doctor or public health department to obtain it. TYPE OF VACCINE*. FIRST DOSE.

Georgia Department of Public Health

a parent/guardian or sent to the new facility. Certified by (Signature/Signature Stamp) Date of Issue. PRINTED BY GEORGIA IMMUNIZATION REGISTRY (GRITS). Notes:

Vaccine Administration Record for Adults

1. With the exception of hepatitis B vaccines record the generic abbrevia- tion (e.g.

Certificate of Immunization Status (CIS) Reviewed by

Health Care Provider or School Official Name: Signature: Date:______. If verified by school or child care staff the medical immunization records must be

Vaccine Administration Record for Children and Teens

Mar 21 2006 ? See page 2 to record measles-mumps-rubella

COVID-19 Vaccine Consent Form

COVID-19 Vaccine Consent Form. Sections A B

Student Immunization Record

If you have questions regarding immunizations or how to complete this form

CH-14 Universal Child Health Record

Immunization Record Attached. Date Next Immunization Due: MEDICAL CONDITIONS. Chronic Medical Conditions/Related Surgeries.

COMMONWEALTH OF PENNSYLVANIA

I understand that the information/records released pursuant to this authorization will include all immunizations/vaccinations reported to the Pennsylvania

Child Care Immunization Record

If you do not have an immunization record for this child contact your doctor or local public health department to obtain the records. TYPE OF VACCINE. First

Immunization Record Form - MN Dept of Health

Immunizations required for child care early childhood programs

IMMUNIZATION RECORD SAMPLES

Sep 13 2021 People can show proof of vaccination with one of the types of official immunization records below

Vaccine Administration Record for Adults

To meet the space constraints of this form and federal requirements fordocumentation a healthcare setting may want to keep a reference list ofvaccinators that includes their initials and titles Immunization Action Coalition Saint Paul Minnesota 651-647-9009 www immunize www vaccineinformation

Vaccine Administration Record for Children and Teens

Record the generic abbreviation (e g Tdap) or the trade name for eachvaccine (see table at right) Record the funding source of the vaccine given as either F (federal)S (state) or P (private) Record the site where vaccine was administered as either RA (right arm)LA (left arm) RT (right thigh) LT (left thigh) or NAS (intranasal)

Immunization Record and History - California

Immunization Record and History PATIENT NAME (Last Name First Name Middle Initial) NUMBER BIRTHDATE Male KNOWN REACTIONS TO VACCINES/ALLERGIES PRACTICE NAME/ADDRESS Female VACCINES FOR CHILDREN (VFC) ELIGIBILITY (check one) Under-insured (insurance does not cover immunizations) American Indian/

Life Time Card - Immunization Action Coalition (IAC)

LIFETIME IMMUNIZATION RECORD Always carry this record with you and have your healthcare professional or clinic keep it up to date Last name First name M I Birthdate: Number: – Printed by Immunization Action Coalition Saint Paul MN www immunize • www vaccineinformation

California School Immunization Record - sfcdcporg

Complete the Documentation and Status of Requirements box A Fill in date and your signature as the staff member who reviewed and transcribed the immunization record presented by the parent or guardian Check which type of record was presented B If the child has met all immunization requirements check box A and write in date C

Searches related to printable immunization records filetype:pdf

You may need your immunization record for child care school camp college the military travel employment or long-term care Sign up to get access to your and/or your family’s To request this document in another format call 1-800-525-0127 Deaf or hard of hearing customers needing assistance please call 711 (Washington

COVID-19 Vaccine Consent FormSections A, B, C, D and E completed by:

A. Client Information - please print

Surname _______________________________________________ Given Names ______________________________________

Address of residence ________________________________ City/Town _______________________ Postal Code _______________

Phone Number ___________________________ Email _______________________________________________________________

Manitoba Health Number (6 digits) _______________

Personal Health Information Number (9 digits) ________________________ __

Name of school ________________________________________ City/Town _________________________ Grade _______________

B. Health History of Client

1. Do you have a fever or other symptoms that could be due to COVID-19? If yes, describe _______________________________________________________ _____________________________________ 2. Do you have any known or suspected allergies (examples: food, medicatio ns, environmental)? If yes, describe _______________________________________________________ _____________________________________ 3. Do you have a known or suspected allergy to polyethylene glycol (PEG), polysorbate 80 or tromethamine? 4. Have you ever had a serious reaction or condition following any vaccine? If yes, describe _______________________________________________________ _____________________________________ 5 Do you have any medical conditions that require regular visits to a doct or?

If yes, please discuss with immunizer _______________________________________________________________________

____ 6.

Have you received a vaccine in the last 14 days?

7. Are you taking any medication that affects blood clotting? If yes, please list _______________________________________________________________________ ____________________ 8. Are you pregnant, planning to become pregnant or breastfeeding? 9. Is your immune system suppressed due to disease (e.g., leukemia) or tr eatment (e.g,. high-dose steroids)? 10. Do you have an autoimmune condition (e.g., Rheumatoid Arthritis, Multiple Sclerosis)?

11. Do you have a history of venous sinus thrombosis in the brain or a histo

ry of heparin-induced thrombocytopenia (HIT)? 12. Have you received any doses of a COVID-19 vaccine? 14. Have you received a monoclonal antibody treatment (e.g., Sotrovimab, C asirivimab, Imdevimab)

MHSU-2823 (April 2022)

C. Racial, Ethnic or Indigenous Identity

Public health has been collecting information about the racial, ethnic, Indigenous identity of individuals who are diagnosed with COVID-19 since May 2020. The following questions will help assess vaccine coverage and determine the need for increased vaccine describe yourself. Keeping that in mind, which of the following best des cribes the racial or ethnic community that you belong to? D. Informed consent - Consult immunizer if no signature can be obtained

above named person as per section A. My consent applies to all doses of the vaccine necessary to complete

the series up to one year. I have had the opportunity to ask questions about the vaccine(s) which were answered to my satisfaction.

Complete ONLY ONE of the following two options:

Consent by legal decision maker

I consent to the above named person receiving the COVID-19 vaccine. Name __________________________________________________ Relationship _____________________________________________ Phone number ___________________________________________ Date (yyyy/mm/dd) ________________________________________ Signature _______________________________________________2. Consent by client

I consent to receiving the COVID-19 vaccine.

Date (yyyy/mm/dd) _______________________________

Signature ______________________________________E. Consent for use and disclosure of contact information

I understand and authorize the Department of Health and Seniors Care' s use and disclosure of the contact information provided by me on this form to a third party organization for the sole purpose of contacting me to schedule my appointment for the second dose

Date __________________________________________

of the vaccine. Signature ______________________________________ Notice: Information about the immunizations you or your dependent(s) r eceive may be recorded in the provincial immunization registry. This registry provincial immunization registry may be used to produce immunization rec ords, or notify you or your doctor if a particular immunization has been missed. Manitoba Health and Seniors Care may use the information to moni tor how well different vaccines work in preventing disease. The Personal

Health Information Act protects your information. You can have your personal health information hidden from view from healt

h care providers. For more THE FOLLOWING SECTION TO BE COMPLETED BY THE IMMUNIZATION PROVIDER Clinic Location ________________________________________________________ _____________________________________ hey are unable to sign section D

Reason for Immunization - please check the

applies) 1. 2. 3. 4. non-health care staff, visitors, volunteers) 5. a check mark by the immunizer: 1. 2. 3. 4. (reportable side effects pursuant to section 57(2) of the

Public Health Act)

5. Clients who answer yes to questions 9, 10 and/or are receiving dose 3 ( as per question 12) of section B: health care provider

Immunizer or Health Care Provider Name (please print): _____________________________________________________________

Immunizer or Health Care Provider Signature: ___________________________ _____________ Date __________________________

VaccineDate

Y/M/DLot #ManufacturerRouteDoseSiteImmunizer's SignatureData Entryquotesdbs_dbs17.pdfusesText_23

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[PDF] COVID-19 Vaccine Consent Form COVID-19 Vaccine Consent Form.

A. Client Information - please print

Manitoba Health Number (6 digits) _______________

B. Health History of Client

Have you received a vaccine in the last 14 days?

11. Do you have a history of venous sinus thrombosis in the brain or a histo

MHSU-2823 (April 2022)

C. Racial, Ethnic or Indigenous Identity

Complete ONLY ONE of the following two options:

Consent by legal decision maker

I consent to receiving the COVID-19 vaccine.

Date (yyyy/mm/dd) _______________________________

Date __________________________________________

Reason for Immunization - please check the

Public Health Act)

VaccineDate