COVID-19 VACCINE DECLINATION FORM
Patient/Resident/Staff Member Information:
First Name: __________________________ Last name: ____________________________
Medical Record #: ______________________
N/A - staff member
Date of Birth: __________________ Age: ___________ Gender: Female Male
I acknowledge that I have read, or had explained to me, the Coronavirus Disease (COVID-19)
General Information handout and the Emergency Use Authorization (EUA) Fact Sheet regarding
the COVID-19 vaccine.
I have had the opportunity to ask questions, which have been answered to my satisfaction and
understand the benefits and risks of the vaccination as described.
I understand that if I decline the vaccine, I may change my mind and request to be vaccinated at
a later date, with the understanding that the vaccination will be based on the availability of the
COVID-19 vaccine at that time.
_____ I wish to refuse the COVID-19 vaccination (or refuse for the person named above for
whom I am authorized to make this request). I understand that I may change my mind
and request to be vaccinated later.
I certify that I am (a) the patient/resident/staff member and at least 18 yrs of age or (b) the
representative of or the legal guardian of the patient/resident named above. I acknowledge that in
making this decision I have had a chance to ask questions and that such questions were answered to
my satisfaction.
________________________________________________________ Date: _____________
Patient/Resident/Staff Member Signature
________________________________________________________ Date: _____________
Legal Representative Signature
PRINT Legal Representative Name: ______________________________________________
Relationship to patient/resident: __________________________________________________
If VERBAL DECLINATION was received for the patient/resident:
________________________________________________________
Print name of person providing verbal declination
________________________________________________________ Date: _____________
Staff Member Signature (person who received verbal declination)
11.53.4.A 12/20
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