CONSENT FOR COVID 19 VACCINATION
Company/Corporate Name:…....................................................... Staff ID Number:…...........
First name:….............................. Middle Name:…........................... Last name:….....................
DOB: ………... /…..……/………... Gender: Male/Female Civil ID number:…...................
Nationality: ……………………………………
Tarassud No:……………………………(to be added on site)
Mobile number:……………………………………….
Second mobile number(own/other) …………………………
Email ID …............................................................(provide ID only if you regularly check your mail)
I hereby confirm that I have fully understood about the benefits and the limitations of COVID 19 vaccination
The vaccine is supplied by the MOH and administered by Starcare team.
I have read (or it has been read to me) and I understand the Immunization Prepackage, includingthe
following documents: ‘COVID-19 Vaccine Information Sheet’ and ‘What you need to know about your
COVID 19 vaccine appointment’
I understood the decision to take COVID19 vaccination is voluntary by me and I am aware of the
potential side effects
I have had/I will have the opportunity to ask questions regarding the vaccine I am receiving and to
have them answered to my satisfaction
Note: Please contact the vaccination clinic where you are supposed to receive the COVID 19 vaccine if you
change your mind and no longer consent to receiving the vaccine. This will allow someone else to take your
spot. If consent has been withdrawn.
Acknowledgement of Collection, Use and Disclosure of Personal Health Information.
The personal health information is being collected for the purpose of providing care to you and creating an
immunization record for you, and because it is necessary for the administration of MOH COVID 19 vaccination
programThe personal health information is being collected for the purpose of providing care to you and creating
an immunization record for you, and because it is necessary for the administration of MOH COVID 19 vaccination
program
The information will be stored in Starcare record system under the custody and control of the Ministry of Health
I acknowledge that I have read and understand the above statement.
Signature……............................... (Only to be signed at Vaccination clinic when asked)
Nurse name:
Employee code:
Signature:
Date:…
Time: SH/MF/120
