I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Pfizer Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.

I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.

I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.

I understand that I will be receiving the vaccination at no cost to me.

On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the state of Tennessee Department of Health (TDOH), and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed in this form.

I acknowledge that: (a) I understand the purpose/benefits of TennIIS Tennessee immunization registry and (b) TDOH will include my personal immunization information and my personal immunization information will be shared with the Centers of Disease Control (CDC) or other federal agencies.