Page 2 of 2 Moderna COVID-19 Vaccine
Effective Date: 1/04/2021
authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under
Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.
• I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the
risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization
Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such
questions were answered to my satisfaction.
• I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes (or more in specific cases) after
administration for observation. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.
• On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the State of Florida, the Florida Department of
Health (DOH), and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and
all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine
• I acknowledge that: (a) I understand the purposes/benefits of Florida SHOTS, Florida’s immunization registry and (b) DOH will include my
personal immunization information in Florida SHOTS and my personal immunization information will be shared with the Centers for Disease
Control (CDC) or other federal agencies.
• I further authorize DOH or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for
me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to DOH or its
agents with respect to the above requested items and services. I understand that any payment for which I am financially responsible is due at
the time of service or if DOH invoices me after the time of service, upon receipt of such invoice.
• I acknowledge receipt of the Notice of Privacy Rights.
Signature of Patient or Authorized Representative Date:
Print Name of Representative and Relationship to Person Receiving Vaccine: __________________________________________________
Unit of Use/
Unit of Sale
Administered at location: facility
Administered at location: Type
Vaccinator Print Name:___________________________________________ Signature: ____________________________________ Date: _______________
Vaccine administering provider suffix: _____________________________________________