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MIA MIDADE COUNTY HEALTH DEPARTMENT Administration Facility Name/Facility ID: COVID-19 VACCINE SCREENING AND CONSENT FORM Moderna COVID-19 Vaccine SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT) EMAIL
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How to fill out moderna consent form

01
Obtain a copy of the Moderna consent form.
02
Read the form carefully to understand the information and requirements.
03
Provide your personal information accurately, including your full name, date of birth, and contact details.
04
Make sure to disclose any relevant medical conditions or allergies.
05
Review the provided information about the Moderna vaccine, its benefits, and potential risks.
06
Sign and date the consent form to indicate your agreement and understanding.
07
If applicable, have a parent or legal guardian sign the form for minors or individuals who are unable to provide consent.
08
Return the completed consent form to the authorized healthcare provider, clinic, or vaccination center.

Who needs moderna consent form?

01
Any individual who wishes to receive the Moderna vaccine needs to fill out the Moderna consent form. This includes eligible individuals as per the health authority guidelines, such as adults over a certain age, individuals with certain medical conditions, and frontline workers.
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The Moderna consent form is a document that individuals must sign to give their permission for the administration of the Moderna COVID-19 vaccine, ensuring they understand the risks and benefits.
Individuals receiving the Moderna vaccine are required to fill out and sign the consent form prior to vaccination.
To fill out the Moderna consent form, provide accurate personal information, read the provided information about the vaccine, and sign the document to indicate your understanding and consent.
The purpose of the Moderna consent form is to inform individuals about the vaccine and obtain their consent for vaccination, thereby ensuring legal compliance.
The Moderna consent form typically requires personal information such as name, date of birth, contact information, and a record of any previous allergic reactions or health conditions.
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