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CONSENTS & ACKNOWLEDGEMENT
By my signature below, I acknowledge and consent as follows:
I understand that COVID-19 is a contagious viral infection of the respiratory tract that can spread from
person to person usually through close contact with an infected person or through respiratory droplets
that are dispersed into the air when an infected person coughs, sneezes, talks, or sings. Droplets can
land in the mouths or noses of people who may be close by. Spread is more likely when people are
within 6 feet of distance of each other. Infection may also occur when a person comes in contact with a
surface contaminated by the referenced droplets.
I understand that as of the date of this of this consent, vaccination is expected to be among the most
effective means of slowing the spread of the COVID-19 infection and ending the ongoing global
pandemic. Further, I understand the vaccine is intended as a two-shot series to maximize efficacy. The
second vaccine administration must be given approximately 21 or 28 days (depending on the specific
vaccine administered) after the initial administration. I also understand that between the first and second
administrations of the COVID-19 vaccine, I should not have any other vaccines administered.
I have received a copy of the COVID-19 vaccine Fact Sheet for Recipients and Caregivers and been
given an opportunity to review it prior to vaccine administration. I may also access such vaccine fact
sheet online through the U.S. Food and Drug Administration at:
www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/covid-19-
vaccines
I acknowledge that such fact sheets, among other things, provide the following:
o The FDA has authorized the emergency use of the COVID-19 Vaccine
o The significant known and potential risks and benefits of the COVID-19 Vaccine, and the
extent to which such risks and benefits are unknown
o Information about available alternative vaccines and the risks and benefits of those
alternatives
I understand that the COVID-19 vaccine, like all medicines, can cause side effects. Most side effects
are mild and short-term and not everyone experiences them. Based on recent CDC guidance, I
understand that anaphylaxis, itching, swelling or respiratory distress within 4 hours of COVID-19
vaccine administration, is a contraindication for receiving a future dose of the COVID-19 vaccine. CDC
guidance also states that a second vaccine should only be considered after an evaluation by an
allergist-immunologist who would determine if I can safely receive the second vaccine. If I experience
severe side effects, I should immediately call 9-1-1 or seek medical attention. Further, I understand that
severe side effects may have to be reported to relevant regulatory authorities, and as such, I will report
all severe side effects to CTCA as the entity who administered my vaccine.
I understand that the COVID-19 vaccine is a two-part vaccine series. By signing this consent, I am
agreeing that I will receive the first and second part of the vaccine series.