COVID-19 Vaccination Consent & Release Form: Downtown

I understand that at this time, the COVID-19 Moderna vaccine requires 2 doses given 28 days apart. If this is my second dose, I will bring my vaccine card with me to be completed (recommended but not required).

I agree to follow the recommended 15-minute observation period or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.

I have read the above information or have had the information explained to me. I have had a chance to ask questions and these have been answered to my satisfaction. I understand the benefits and the risks of the Covid-19 vaccine and ask that the vaccine is given to me, or to the person named above for whom I am authorized to make this request. I accept responsibility for seeking medical attention for any problems with this vaccination. I authorize billing the administration fee to my healthcare insurance.