Date of Birth
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I, the undersigned, give my consent for the services that I am requesting from Passport Health and its entities/contractors. I acknowledge that I received the Vaccine Manufacturer COVID-19 Fact Sheet for Recipients and Caregivers prior to receiving the vaccine and have had the opportunity to ask questions to my satisfaction. I understand that there are risks and uncertainties inherent in vaccination, I waive and release any claims against Passport Health or its associated persons relating to or resulting therefrom, including any adverse reaction or other consequence of the vaccination, and I request it be administered to me or to the recipient, on whose behalf I am authorized to make this consent, waiver and release. I may request the Notice of Health Information Practices (HIPAA) and I authorize my immunization record to be recorded with the State Vaccine Registry and released to employer, school, and/or physician if requested.
Information from Pfizer regarding the COVID vaccine can be found here |