THE MINISTRY OF HEALTH OF VIETNAM THE SOCIALIST REPUBLIC OF VIETNAM

BACH MAI HOSPITAL Independence – Freedom – Happiness

CONSENT FORM FOR COVID – 19 VACCINATION

Full name: Date of birth:

Country of birth: Passport number:

Address: Phone contact number:

1. COVID – 19 Vaccination is an effective way to prevent you from Covid-19, but the
vaccine might not be effective. Being fully vaccinated could protect you from Covid-
19, and it could reduce the severity of illness if you get infected. After being
vaccinated, you must still fully follow the public health precautions (5K message) as
required to stop the spread of COVID-19.

2. You may have some common side effects on the arm or the rest of your body such as:
swelling, pain, redness, headache, nausea, fever, muscle pain, and etc or severe
complications after vaccination.

3. Kindly contact the nearest medical facility for advice, examination, and timely
treatment if you have any abnormal side effects after vaccination.

I have read and understood the risks of Covid – 19 vaccination and:

I consent to receive the vaccine

I disagree to receive the vaccine

Hanoi, …. August…. 2021