COVID Vaccine Consent Forms

Residents residing in the facility are now eligible to receive the COVID-19 vaccine. It is not mandatory for residents to receive vaccine. Please download and complete both PDFs below and return them via email to [email protected] or drop it off at the front desk by January 20th. Consents returned after the 20th are not guaranteed a vaccine. Power of Attorneys and Responsible Parties must complete both forms in order to complete registration.

RESIDENT’S SCHEDULED TO RECEIVE THEIR 2ND DOSE ON THE 31ST MUST COMPLETE ANOTHER CONSENT FORM IN ORDER TO REGISTER.

The vaccines will be administered here in our facility by a trained CVS Pharmacy team.

The vaccine has been approved by the FDA for emergency use, and studies have found it safe and effective. It takes two doses for the vaccine to work. We will automatically schedule the follow up appointment. No additional forms will be necessary.

External vaccine resources:

More information from Moderna

More information from AHCA NCAL

More information from the CDC

COVID 19 Vaccine Intake Fillable Consent Form

COVID 19 Vaccine Responsible Party Form