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COVID-19 Vaccine Informed Consent - Resident/Client

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SKU: 7125P

This new form provides for informing the resident/client about COVID-19 illness and is used to document consent or declination of the COVID-19 vaccine. It includes information regarding:

         Brief discussion of how the coronavirus is spread   

         Clinical symptoms of COVID-19 illness

         Populations that should receive the COVID-19 vaccine

         Who should not receive or wait for the vaccine

         Clinical side effects of the vaccine

         2 currently available vaccines: Pfizer-BioNTech and Moderna with hyperlinks to obtain the current Fact Sheets for each as part of obtaining informed consent [no VIS available as these vaccines are provided via EUA (Emergency Use Authorization) at this time]

         Option to sign for the consent of the specific vaccine to be given, by resident/client or their representative

         Option to decline the vaccine, by resident/client or their representative 

         Witness signature 


Download a Sample Now!

Size:  8 1/2" x 11"
Paper:  White
Print:  Black ink; 2-sides different
Punching:  5-holes top and side
Packaging:  100 per pad

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