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Minor Screening and Parental or Guardian Consent for the Pfizer COVID-19 Vaccine SECTION 1: MINOR VACCINE RECIPIENT INFORMATION Last Name: ___ First Name: ___ Middle: ___ Address: ___ City: ___ Zip:

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How to fill out ldhlagovassetsophcovid-19 vaccine consent and

01

Download the ldhlagovassetsophcovid-19 vaccine consent form from the LDH website.

02

Fill out all necessary personal information such as name, date of birth, address, etc.

03

Read through the consent form carefully and sign where indicated.

04

If the vaccine recipient is a minor or unable to consent, a parent or legal guardian must also sign the form.

05

Bring the completed consent form to your vaccination appointment.

Who needs ldhlagovassetsophcovid-19 vaccine consent and?

01

Individuals who are under the age of 18 and receiving the COVID-19 vaccine.

02

Individuals who are unable to provide consent for themselves.

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What is ldhlagovassetsophcovid-19 vaccine consent and?

ldhlagovassetsophcovid-19 vaccine consent is a form that individuals need to fill out to give their consent for receiving the COVID-19 vaccine.

Who is required to file ldhlagovassetsophcovid-19 vaccine consent and?

Individuals who are eligible to receive the COVID-19 vaccine are required to fill out ldhlagovassetsophcovid-19 vaccine consent form.

How to fill out ldhlagovassetsophcovid-19 vaccine consent and?

To fill out ldhlagovassetsophcovid-19 vaccine consent form, individuals need to provide their personal information, medical history, and consent for receiving the COVID-19 vaccine.

What is the purpose of ldhlagovassetsophcovid-19 vaccine consent and?

The purpose of ldhlagovassetsophcovid-19 vaccine consent form is to ensure that individuals give their informed consent before receiving the COVID-19 vaccine.

What information must be reported on ldhlagovassetsophcovid-19 vaccine consent and?

ldhlagovassetsophcovid-19 vaccine consent form may require information such as name, date of birth, contact information, medical history, and consent for receiving the COVID-19 vaccine.

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