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Pfizer-BioNTech COVID CONSENT 2021 Information about the person receiving the vaccine (Please Print)

Last Name: First Name: Date of Birth:

Mailing Address: Apt/Suite:

City: State: Zip: County: Phone Number:

Sex: □ Male □ Female Gender Identity: □ Male □ Female □ MTF □ FTM □ Nonbinary □ Questioning

Race: Hispanic Origin: □ Asian □ Black □ Non-Hispanic □ American Indian/Alaskan Native □ White □ Hispanic □ Unknown □ Hawaiian/Pacific Islander □ Other: ______

Have you previously received a COVID-19 vaccine? * □ Yes □ No □ I don’t know Have you had a severe allergic reaction (e.g., ) after receiving COVID-19 vaccine or any medication given via or polyethylene glycol (MiraLAX)? □ Yes □ No □ I don’t know Are you immunocompromised (have a weakened immune system such as cancer, leukemia, HIV/AIDS, or any other immune system problem) or are you taking medication that affects your immune system? □ Yes □ No □ I don’t know In the last 10 days, have you had a or any ill symptoms or been exposed to COVID? □ Yes □ No □ I don’t know Have you had any in the last 14 days? □ Yes □ No □ I don’t know

Have you received COVID therapy in the last 90 days? □ Yes □ No □ I don’t know Could you become pregnant in the next several weeks or are you breastfeeding? * If so, you must speak with your OB prior to making the appointment. □ Yes □ No □ I don’t know Consent for COVID-19 You must sign this to be VACCINATED. By signing this form, I give permission for a COVID-19 VACCINATION to be administered and a record of the VACCINE and results be entered into a database for use to monitor control of the disease. Further, I agree that the information above is correct, and: * I have read information about the VACCINATION or someone has explained it to me; * I understand the risks and benefits of being VACCINATED and consent to be VACCINATED, and * Any questions I had about the VACCINATION have been answered. (1) The information provided is correct (2) I have read the EUA Fact Sheet provided (3) I understand the risks and benefits of getting the vaccine(s) and consent for me and my family to be vaccinated (4) Any questions I had about the vaccine(s) have been answered.

X______Signature Date Email

DATE GIVEN:______LOT#______L or R (IM) Signature of Vaccinator

Revised 2/17/2021

Revised 2/17/2021