Safeway Covid Booster Consent Form. Last name first name identification (e.g., health card number) gender: 5) i have been counseled.
A n sw e r q u e s t i o n s o n p ag e 2. Use fill to complete blank online others pdf forms for free. I hereby consent to have the vaccine administered to me by the company pharmacist.
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Safeway Recommends That You Check The Safeway Website For Updates And Dates When More Vaccines Will Become Available.
I am of legal age and authorized to execute this consen t form or i am the parent/guardian of the minor patient. 5) i have been counseled. Information about you (please print) last name utsa id (abc123) date of birth :
Informed Consent For Immunization With Inactivated Vaccine.
Delivery quality and convenience delivered right to your door. Race,tetnmclty (please occupations natural resources, agricultl business, finance an. I understand that if my vaccine requires two doses, i will need to be administered (given) two doses to be considered fully vaccinated.
A N Sw E R Q U E S T I O N S O N P Ag E 2.
Client parent legal decision maker other _____ (on behalf of client) Get all of your pharmacy, immunization, and prescription refill needs with safeway pharmacy today. Choose how you would like to shop.
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Age in years sex (gender assigned at birth) month day year male female: Once completed you can sign your fillable form or send for signing. Last updated 17 may 2021
A Prescription Is Recommended For Astrazeneca As A Booster Dose Or A Second Primary (Ie.
Please answer the following questions with a yes or no answer. 4) i will immediately alert the pharmacist of any medical conditions which may adversely affect my personal health or effectiveness of the vaccine. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated.