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Covid-19 Vaccine Screening And Consent Form In Spanish

Covid-19 Vaccine Screening And Consent Form In Spanish. Screening for vaccine eligibility yes no I understand that any monies or benefits for administering the

Mass vaccination sites open in New York City as COVID19 from www.yahoo.com

Information about minor child to receive vaccine (please print) minor’s name (last) (first) (m.i.) minor’s date of birth (mm/dd/year): Information about you (please print) last name I understand there will be no cost to me for this vaccine.

Last Name First Name Middle Initial.

Jr, iii) date of birth (mm/dd/yyyy) age. 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.

Information About You (Please Print) Last Name

Or (c) legally authorized to consent for vaccination for the patient named above. Signature (parent or guardian) date. I understand there will be no cost to me for this vaccine.

I Understand There Will Be No Cost To Me For This Vaccine.

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 Screening for vaccine eligibility yes no Dha forms management office subject:

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

Dha form 207, nov 2021 created date If any vdh health care professional, worker or employee. Page 1 of 2 effective date:

(B) The Legal Guardian Of The Patient And Confirm That The Patient Is At Least 12 Years Of Age (For Pfizer Vaccine Consent Only);

I understand that any monies or benefits for administering the I understand that if my vaccine requires two Date of birth are you a minor less than 18 yrs old sex yes.

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