COVID-19 Vaccine Information & Consent Form for children 5-11

Information and Consent about the child to receive Pfizer COVID-19 Vaccine

Information about the Pfizer Vaccine
Your child is being offered a COVID-19 vaccine made by Pfizer-BioNTech. The Pfizer- BioNTech COVID-19 Vaccine is approved by the U.S. Food and Drug Administration (FDA) for people over 16 years old, with the brand name Comirnaty. The FDA has also issued an Emergency Use Authorization for Pfizer-BioNTech COVID-19 Vaccine for people ages 5 and older. Both the Pfizer-BioNTech COVID-19 Vaccine and Comirnaty are administered as a 2-dose series, 3 weeks apart, into the muscle. The vaccine provider will need certain information about your child’s medical history before administering the vaccine. Those questions are available here www.mass.gov/CDCScreeningForm
The vaccine may not protect everyone from COVID-19 disease. Some people may experience side effects after getting the vaccine. Side effects that have been reported include injection site pain, tiredness, headache, muscle pain, chills, joint pain, fever, injection site swelling, injection site redness, nausea, feeling unwell, and swollen lymph nodes. There is a remote chance that the vaccine could cause a severe allergic reaction. A severe allergic reaction would usually occur within a few minutes to one hour after getting a dose of the vaccine. For this reason, a vaccination provider may ask the person receiving the vaccine to stay at the place where they received their vaccine for monitoring after vaccination. Signs of a severe allergic reaction can include difficulty breathing, swelling of the face and throat, a fast heartbeat, and/or a bad rash all over the body.
CONSENT FOR MINOR’S VACCINATION: I have reviewed the information about the Pfizer- BioNTech and Comirnaty COVID-19 Vaccines in Section 2 above and understand the risks and benefits. In providing my consent below, I agree that:
  1. I have reviewed this consent form, and I understand that the “Fact Sheet for Recipients and Caregivers,” includes more detailed information about the potential risks and benefits of the Pfizer-BioNTech and Comirnaty COVID-19 Vaccines.
  2. I have the legal authority to consent to have the child named above vaccinated with the Pfizer-BioNTech or Comirnaty COVID-19 Vaccine.
  3. I understand I am not required to accompany the child named above to their vaccination appointment and that, by giving my consent below, the child will receive the Pfizer-BioNTech or Comirnaty COVID-19 Vaccine whether or not I am present at the vaccination appointment.
  4. If I have health insurance that covers the child named above, I give permission for my insurance company to be billed for the costs of administering the Pfizer Comirnaty COVID-19 Vaccine. The government is paying for the Pfizer Comirnaty COVID-19 Vaccine itself, and I will not be billed for that portion of the cost of my immunization.
  5. I understand that my vaccine information will be sent to ImmTrac2: The Texas Immunization Registry (ImmTrac2). ImmTrac2 is a free service of the Texas Department of State Health Services (DSHS). ImmTrac2 is a secure and confidential service that consolidates immunization records for public health purposes (e.g., giving all doctors treating a patient a central place to see that patient’s immunization records). In addition to my agreement and consent below, I GRANT consent for registration and wish to INCLUDE my information in the Texas immunization registry. https://www.dshs.texas.gov/immunize/ImmTrac/
   
I GIVE CONSENT for the child named at the top of this form to get vaccinated with the Pfizer-BioNTech or Comirnaty COVID-19 Vaccine and have reviewed and agree to the information. (If this consent is not signed, dated, and returned, the child will not be vaccinated.)
Clear

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