UI Health COVID-19 Vaccine Consent Form
This consent form is essential for individuals receiving the COVID-19 vaccine at UI Health. It outlines the acknowledgment of benefits, risks, and personal information collection associated with vaccination. Signing this form indicates informed consent and understanding of the associated processes.
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How do I fill this out?
Filling out this form is straightforward. Begin by entering your personal information in the specified fields. Once all sections are completed, review for accuracy, sign, and submit.
How to fill out the UI Health COVID-19 Vaccine Consent Form?
1
Read the form thoroughly to understand its requirements.
2
Fill in your personal details including name and contact information.
3
Indicate your consent regarding the COVID-19 vaccine.
4
Sign and date the form as required.
5
Submit the completed form to the appropriate health authority.
Who needs the UI Health COVID-19 Vaccine Consent Form?
1
Individuals aged 6 months to 11 years receiving the vaccine.
2
Parents or guardians authorizing vaccination for minors.
3
Health care professionals needing consent documentation.
4
Researchers conducting studies related to vaccine effectiveness.
5
Public health officials tracking vaccination rates.
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What are the instructions for submitting this form?
To submit the completed COVID-19 Vaccine Consent Form, email it to uihealthvaccination@uillinois.edu or fax it to (312) 996-8888. You may also choose to submit the form through our online patient portal. For direct submissions, please deliver the form to your nearest UI Health vaccination site.
What are the important dates for this form in 2024 and 2025?
The COVID-19 Vaccine Consent Form is applicable as of now and continues to be necessary for appointments in 2024 and beyond. Ensure timely submission prior to your vaccination date to avoid any potential delays in service. Stay updated for any changes to the vaccination guidelines in 2025.
What is the purpose of this form?
The primary purpose of this form is to obtain informed consent from patients receiving the COVID-19 vaccine. It details the risks, benefits, and alternatives to vaccination, ensuring that individuals understand their rights and responsibilities. Additionally, the consent form serves as a legal agreement between the patient and the health care provider, safeguarding both parties by documenting the patient's agreement to receive the vaccine.
Tell me about this form and its components and fields line-by-line.
- 1. Last Name: The patient's last name must be entered.
- 2. First Name: The patient's first name must be provided.
- 3. MI: Middle initial of the patient, if applicable.
- 4. Date of Birth: Date of birth in MM-DD-YY format.
- 5. Cell Phone: Patient's contact number.
- 6. Email: Patient's email address.
- 7. Signature: Patient's electronic signature indicating consent.
- 8. Date: Date when the form was signed.
- 9. Parent/Guardian Signature: Separate signature for a guardian, if applicable.
- 10. Relationship: Relationship of the guardian to the patient.
What happens if I fail to submit this form?
If this form is not submitted, individuals may be unable to receive their scheduled COVID-19 vaccination. This can lead to delays in medical treatment and potential health risks associated with the virus. Submitting the form is essential for ensuring adherence to vaccination protocols.
- Delay in Vaccination: Failure to submit the form may result in postponed vaccination appointments.
- Legal Implications: Without consent, medical providers cannot administer the vaccine.
- Health Risks: Not being vaccinated increases the risk of contracting COVID-19.
How do I know when to use this form?
- 1. Receiving the COVID-19 Vaccine: Individuals receiving the vaccine are required to complete this form.
- 2. Parental Consent: Guardians must fill out this form for minors receiving vaccines.
- 3. Health Documentation: Health care providers use this form for record-keeping and compliance.
Frequently Asked Question
How do I fill out the COVID-19 Vaccine Consent Form?
You can easily fill out the form by entering your personal information in the provided fields and signing where indicated.
Can I edit the PDF before filling it out?
Yes, you can edit the PDF using PrintFriendly to add your details before signing.
What if I am a guardian filling this out for someone?
As a guardian, you can fill out the consent form on behalf of the minor and must sign it accordingly.
Is my personal information kept confidential?
Yes, all personal information entered in the consent form is handled with strict confidentiality.
Can I share the completed form?
Absolutely! After completing the form, you can easily share it via a generated link.
What if I don’t have a printer?
You can edit and sign the form digitally, allowing you to submit it without printing.
How do I submit the consent form?
You can submit the completed form electronically through the designated health authority's submission portal.
What if I need to make changes after signing?
If you need to make changes, simply edit the PDF again, sign it, and re-submit.
Are there any fees associated with the consent form?
No, filling out the consent form and accessing it on PrintFriendly is free of charge.
Why is this consent form necessary?
This form ensures that you are informed about the vaccination and consent to the procedure.
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