CONSENT TO COVID-19 VACCINATION AND RELATED TREATMENT FOR MINOR WITHOUT
A PARENT/LEGAL REPRESENTATION
Consent is required for vaccination of patients under the age of 18 without a parent/legal representative present.
Minor Patient Date of Birth:
Name: ______________________________________________
Relationship to Minor: _________________________________
Phone Number: ______________________________
I am the: ___ Parent of the minor patient ___ Legal guardian of the minor patient
_
__ Other person with authority to make healthcare decisions on behalf of the minor patient, describe legal
r
elationship: ____________________________________________
I
hereby attest to the following:
• The minor patient is 12 years of age or older
• I have the legal authority to consent to the administration of the Pfizer-BioNTech COVID-19 Vaccine to the
minor
patient
• I understand that the U.S. Food and Drug Administration (“FDA”) has authorized the emergency use of the Pfizer-
BioNTech COVID-19 Vaccine, which is not an FDA-approved vaccine.
• I have been provided access to and read the Pfizer-BioNTech COVID-19 Vaccine EUA Fact Sheet for Recipients
and Caregivers (“Fact Sheet”). (Read the Fact Sheet at https://www.fda.gov/media/144414/download or scan
the QR code at the bottom of this form).
• I understand the known and potential risks and benefits of Pfizer-BioNTech COVID-19 Vaccine and the extent to
which such risks and benefits are unknown.
• I understand that I have the option to accept or refuse Pfizer-BioNTech COVID-19 Vaccine on behalf of the minor
patient.
• I understand that the Pfizer-BioNTech COVID-19 Vaccine is a two-part vaccine series.
• I consent to and authorize all medically necessary treatment in the rare event that the minor patient has a
reaction to the vaccine, including but not limited to itching, swelling, fainting, anaphylaxis, and other reactions.
• The minor patient and I agree that the minor patient will remain in the observation area for the required time
period following vaccine dose administration.
• I consent to the administration of two separate doses of Pfizer-BioNTech COVID-19 Vaccine spaced
approximately three weeks apart to the minor patient.
_________________________________________________________________________________
Printed Name of Parent, Legal Guardian, or Other Authorized Individual Date
_________________________________________________________________________________
Signature of Parent, Legal Guardian, or Other Authorized Individual Date
