Under 5 Vaccines

Infant/Toddler Pfizer (6months-4years): Dose 1, Dose 2 (~21 days after 1st dose), Dose 3 (~8 weeks after 2nd dose)
Infant/Toddler Moderna (6months-5years): Dose 1, Dose 2 (~28 days after 1st dose)

Parental Consent: The patient is a minor and eligible for the Pfizer-BioNTech or Moderna COVID-19 vaccine.
• I have the legal authority to consent to the administration of the Pfizer-BioNTech or Moderna 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 and Moderna vaccines.
• I have been provided access to and read the relevant COVID-19 Vaccine EUA Fact Sheet for Recipients and Caregivers (“Fact Sheet”).
• I understand the known and potential risks and benefits of Pfizer-BioNTech or Moderna COVID-19 vaccines and the extent to which such risks and benefits are unknown.
• I understand that I have the option to accept or refuse COVID-19 vaccine on behalf of the minor patient.
• I understand that the Pfizer-BioNTech and Moderna COVID-19 vaccines are multi-dose 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 Pfizer-BioNTech or Moderna COVID-19 vaccine, including any additional required doses to complete the series.