INFORMATION ABOUT MINOR CHILD TO RECEIVE VACCINE (PLEASE PRINT)
The following questions will help determine if there is any reason your child should not receive a COVID immunization injection:
I have read, or have had explained to me, the Emergency Use Authorization (EUA) for COVID-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of COVID-19 vaccine and ask that the vaccine be given to the child named above for whom I am authorized to make this request (parent or guardian) by Future Pharmacy. I agree for my child’s information to be reported to the NJ State Immunization Registry. I authorize my insurance to be billed to process my child’s claim.
Clear
FOR PHARMACY USE ONLY
Select a country first.