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Information about person to receive vaccine (please print)


The following questions will help determine if there is any reason you 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 me or the person named above for whom I am authorized to make this request (parent or guardian).
I agree for my information to be reported to the NJ State Immunization Registry. I authorize my insurance to be billed to process my claim.

I HAVE BEEN ADVISED TO WAIT FOR 15-30 MINUTES OF OBSERVATION AFTER RECEIVING MY VACCINE BEFORE LEAVING.

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