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Informed Consent Form For The Astrazeneca Covid-19 Vaccine
Informed Consent Form For The Astrazeneca Covid-19 Vaccine
Address:
Health facility:
INFORMED CONSENT
I confirm that I have been provided with and have (PhilHealth) program in case I experience
read the AstraZeneca COVID-19 vaccine and hospitalization due to severe and/or serious
Emergency Use Authorization (EUA) Information adverse reactions caused by the said vaccine.
Sheet and the same has been explained to me. The
FDA has authorized the use of the AstraZeneca I authorize releasing all information needed for
vaccine under an EUA since the gathering of public health purposes including reporting to
scientific evidence for the approval of the said applicable national vaccine registries, consistent
Vaccine and any other COVID-19 vaccine is still with personal and health information storage
ongoing. protocols of the Data Privacy Act of 2012.
I confirm that I have been screened for conditions I hereby give my consent to be vaccinated with the
that may merit deferment or special precautions AstraZeneca COVID-19 Vaccine.
during vaccination as indicated in the Health
Screening Questionnaire.
I was provided an opportunity to ask questions, all In case eligible individual is unable to sign:
of which were adequately and clearly answered. I, I have witnessed the accurate reading of the
therefore, voluntarily release the Government of the consent form and liability waiver to the eligible
Philippines, the vaccine manufacturer, their agents individual; sufficient information was given and
and employees, as well as the hospital, the medical queries raised were adequately answered. I
doctors and vaccinators, from all claims relating to hereby confirm that he/she has given his/her
the results of the use and administration of, or the consent to be vaccinated with the AstraZeneca
ineffectiveness of the AstraZeneca COVID-19 COVID-19 Vaccine.
vaccine.