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ALBERTA COVID19 PHARMACY IMMUNIZATION PROGRAM CONSENT & SCREENING FORM Personal Information for the person being immunized Name (Last, First,Middle)Date of Birth (ddmmyy)Weight:Personal Health Number
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How to fill out immunization consent and information

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How to fill out immunization consent and information

01
Obtain the immunization consent form from your healthcare provider or relevant authority.
02
Fill in your personal information, including your name, date of birth, and contact details.
03
Provide information regarding the immunization being administered, including the type and date of vaccination.
04
Review any potential risks or side effects associated with the vaccination as outlined in the consent form.
05
Sign and date the consent form to acknowledge that you understand the information provided and agree to the immunization.

Who needs immunization consent and information?

01
Parents or guardians of minors receiving immunizations.
02
Individuals receiving vaccinations themselves, especially if they are adults.
03
Healthcare providers administering vaccines to ensure proper documentation.
04
Individuals receiving immunizations under special circumstances, such as those with medical conditions.
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Immunization consent and information refer to the documentation that grants permission for a person, usually a minor, to receive vaccines, as well as the details surrounding the immunization process, including risks, benefits, and vaccine type.
Typically, parents or guardians of minors are required to file immunization consent and information. In some cases, it may also involve individuals who are administering the vaccines.
To fill out immunization consent and information, individuals must provide personal details such as the patient's name, date of birth, and vaccination history, along with a signature indicating consent for immunization and acknowledgment of the information provided.
The purpose of immunization consent and information is to ensure that patients or their guardians are informed about the immunization process, authorize the administration of vaccines, and document the consent for medical and legal purposes.
Required information typically includes the patient’s name, date of birth, vaccination type, administration site, date of vaccination, and the signature of the parent or guardian providing consent.
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