Informed Consent and Release of Information

Spanish VersiĆ³n

You will sign a physical copy of this form when you arrive for your vaccination. There is no need to print this page out and bring it with you. The text is provided for informational purposes only.

I voluntarily consent to and request that the COVID-19 vaccine be given to me. I represent that I lawfully can consent to receive health care services or that I am the lawful parent or guardian of the individual to be vaccinated.

I understand that the COVID-19 vaccine may be administered in multiple doses. If my vaccine requires a series of doses administered through multiple injections, I understand and agree that these terms will apply to the entire vaccination series.

I understand that I must answer a series of health questions before receiving this vaccine. I have been asked those questions, and I have answered them truthfully.

Although the COVID-19 vaccine may prevent me from contracting COVID-19, I understand that no vaccine can be guaranteed to be effective. The COVID-19 vaccine may not protect everyone, and the duration of any protection is unknown. I also understand that I am receiving a vaccine that has been authorized for emergency use pursuant to an Emergency Use Authorization (EUA). I understand that there is no U.S. Food and Drug Administration (FDA) approved vaccine to prevent COVID-19 at this time. In addition, I understand that the administration of any vaccine, including the COVID-19 vaccine, involves the risk of both short- and long-term side effects, including potentially serious or severe complications. The administration of this vaccine also could cause a severe allergic reaction in some individuals. Any side effects or reactions may be severe and unanticipated. I confirm that I have received and read or had read to me the available federal information sheets on the EUA and/or the vaccine, including the FDA fact sheet concerning the vaccine and EUA and any vaccine information statements provided by the Centers for Disease Control and Prevention (CDC), if available at the time of my vaccination. I have had the opportunity to ask any questions I have regarding the vaccine, and those questions have been answered to my satisfaction. I have considered my health circumstances along with the risks and benefits of the COVID-19 vaccine, and I knowingly and voluntarily consent to accept this vaccine.

I agree to comply with any instructions at the vaccination site, including to remain for observation. Further, I agree to return in a timely fashion as instructed for any additional vaccine injections as necessary.

I consent to the disclosure of my information associated with the COVID-19 vaccine to any University of Alabama official or to officials of any affiliated, related, or associated entity as appropriate to respond to the COVID-19 pandemic, and to any entity or individual that may assist with payment, treatment, or healthcare operations. I also understand that my information may be disclosed as otherwise required or permitted by law.

I confirm that I have read and understand this document or that it has been read to me and I understand it.