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 of this vaccine in order for it to be effective.
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.