Pre-Vaccination Screening and Consent for COVID-19 Vaccination


You have selected to receive a COVID-19 vaccine to prevent Coronavirus Disease 2019 (COVID-19). The following information will help your healthcare provider identify and address potential risks related to the vaccine. If a question is unclear, please ask your healthcare provider to explain it. If you answer “Yes” to any question, it does not necessarily preclude you from being vaccinated, but your healthcare provider may need to ask you additional questions.


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