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  • Consent Form

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    Jeffrey Han Sy Vanbelgica
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    This document is a COVID-19 vaccination consent form from the Bureau of Fire Protection in the Philippines. It states that the individual understands the benefits and possible side effects of the COVID-19 vaccine and is not experiencing any flu-like symptoms. They consent to receiving the first and second doses of the vaccine. They also understand their responsibility to report any adverse effects and acknowledge that they do not hold the Bureau of Fire Protection or vaccination team liable for any issues from the vaccination process. The individual must sign and date the form with a witness.

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    Consent-Form

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    This document is a COVID-19 vaccination consent form from the Bureau of Fire Protection in the Philippines. It states that the individual understands the benefits and possible side effects of the COVID-19 vaccine and is not experiencing any flu-like symptoms. They consent to receiving the first and second doses of the vaccine. They also understand their responsibility to report any adverse effects and acknowledge that they do not hold the Bureau of Fire Protection or vaccination team liable for any issues from the vaccination process. The individual must sign and date the form with a witness.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    7 views1 page

    Consent Form

    Uploaded by

    Jeffrey Han Sy Vanbelgica
    This document is a COVID-19 vaccination consent form from the Bureau of Fire Protection in the Philippines. It states that the individual understands the benefits and possible side effects of the COVID-19 vaccine and is not experiencing any flu-like symptoms. They consent to receiving the first and second doses of the vaccine. They also understand their responsibility to report any adverse effects and acknowledge that they do not hold the Bureau of Fire Protection or vaccination team liable for any issues from the vaccination process. The individual must sign and date the form with a witness.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Form No.

    C-2
    Republic of the Philippines
    Department of the Interior and Local Government
    BUREAU OF FIRE PROTECTION
    NATIONAL HEADQUARTERS
    Agham Road, Barangay Bagong Pag-asa, Quezon City
    Telefax Number: (02) 8376-0117
    Email: bfp_nhq_do@yahoo.com

    COVID-19 Vaccination Consent Form


    I _______________________, hereby understood the information provided to me on the COVID-19
    vaccination benefits and its possible effects. Thus, I am asserting that I am free from any flu-like signs and
    symptoms such as fever, body aches, cough and colds and other health conditions during the time of
    vaccination. Hence, I voluntarily submit myself to receive COVID-19 vaccine/s: First Dose: ____; Second
    Dose: ____.

    Moreover, I also understand my responsibility to report and submit myself to proper authorities for
    evaluation of any untoward incidents or effects attributed to vaccination.

    Further, I acknowledge that I do not hold any person or member of the Bureau of Fire Protection or the
    Vaccination Team of any administrative and/or criminal liabilities on account of the vaccination process in
    which I voluntarily submit myself into.

    Rank/Name

    Assignment/Region

    Signature Witness

    Date

    Form No. C-2


    Republic of the Philippines
    Department of the Interior and Local Government
    BUREAU OF FIRE PROTECTION
    NATIONAL HEADQUARTERS
    Agham Road, Barangay Bagong Pag-asa, Quezon City
    Telefax Number: (02) 8376-0117
    Email: bfp_nhq_do@yahoo.com

    COVID-19 Vaccination Consent Form


    I _______________________, hereby understood the information provided to me on the COVID-19
    vaccination benefits and its possible effects. Thus, I am asserting that I am free from any flu-like signs and
    symptoms such as fever, body aches, cough and colds and other health conditions during the time of
    vaccination. Hence, I voluntarily submit myself to receive COVID-19 vaccine/s: First Dose: ____; Second
    Dose: ____.

    Moreover, I also understand my responsibility to report and submit myself to proper authorities for
    evaluation of any untoward incidents or effects attributed to vaccination.

    Further, I acknowledge that I do not hold any person or member of the Bureau of Fire Protection or the
    Vaccination Team of any administrative and/or criminal liabilities on account of the vaccination process in
    which I voluntarily submit myself into.

    Rank/Name

    Assignment/Region

    Signature Witness

    Date

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