Covid-19 Vaccine Screening And Consent Form In Spanish

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Covid-19 Vaccine Screening And Consent Form In Spanish. Information about minor child to receive vaccine (please print) minor’s name (last) (first) (m.i.) minor’s date of birth (mm/dd/year): I consent to receiving the vaccine, including all recommended doses in the series.

COVID19 Vaccine Family Health Care from www.familyhealthcare.org

I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the I consent to receiving the vaccine, including all recommended doses in the series.

If Individuals With Appointments Complete The Consent Form Online Through The Appointment.

(a) the patient and at least 18 years of age; Last name first name middle initial. I understand that if my vaccine requires two

Screening For Vaccine Eligibility Yes No

I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the Or (c) legally authorized to consent for vaccination for the patient named above.

Vdh Client Id# Last Name First Name Middle Name Birth Date.

Jr, iii) date of birth (mm/dd/yyyy) age. If any vdh health care professional, worker or employee. Date of birth are you a minor less than 18 yrs old sex yes.

Information About You (Please Print) Last Name

Patient information (staff only) appointment id: Information about minor child to receive vaccine (please print) minor’s name (last) (first) (m.i.) minor’s date of birth (mm/dd/year): Dha forms management office subject:

Page 1 Of 2 Effective Date:

Dha form 207, nov 2021 created date Last name first name middle name (optional) mother’s maiden name (optional) date of birth (mm/dd/yyyy) gender address no address available insurance information Information about patient (please print)

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