Consent FORM for COVID-19 Vaccination and Testing
- I certify that I am: (a) the patient and at least 12 years of age (Vaccination); (b) the legal guardian of the patient and confirm that the patient is at least 12 years of age; or (c) legally authorized to consent for vaccination or COVID-19 diagnostic testing for the patient named above. Further, I hereby give my consent to the Illinois Department of Public Health (DPH) or its agents to administer the COVID-19 vaccine or COVID-19 diagnostic testing.
- I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under a EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals either 12 years of age or older; and the emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.
- I understand that my COVID-19 diagnostic test will require the collection of an appropriate sample by my healthcare provider through nasopharyngeal swab, oral swab, or other recommended collection procedures. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false-positive or false-negative test results. Should I have questions or concerns regarding my results I will seek advice from an appropriate medical provider.
- I understand that it is not possible to predict all possible side effects or complications associated with receiving the vaccine(s). I understand the risks and benefits associated with the above vaccine and have received, read, and/or had explained to me the Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.
- I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes (or more in specific cases) after administration for observation. If I experience a severe reaction or worsening of my condition, I will call 9-1-1 or go to the nearest hospital.
- On behalf of myself, my heirs, and personal representatives, I hereby release and hold harmless the State of Illinois, Illinois Department of Public Health (IDPH), Immunizations section, Illinois Comprehensive Automated Immunization Registry (I-CARE) and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.
- I acknowledge that: (a) I understand the purposes/benefits of Immunization Portal, Illinois Comprehensive Automated Immunization Registry (I-CARE) and (b) IDPH will include my personal immunization information in I-CARE and my personal immunization information, and my test results will be shared with the Centers for Disease Control (CDC) or other federal agencies.
- I further authorize organization, or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for me for the above-requested items and services. I assign and request payment of authorized benefits be made on my behalf to the organization, or its agents with respect to the above requested items and services. I understand that any payment for which I am financially responsible is due at the time of service or if the organization invoices me after the time of service, upon receipt of such invoice.
- I acknowledge receipt of the IDPH Notice of Privacy Practices.