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GENERAL INFORMATION: The Food and Drug Administration (FDA) gave Emergency Use Authorization on the use of Covid19 Vaccines. COVID-19 vaccines require two separate doses given about three or four weeks apart. Participants of clinical trials have reported experiencing short-term side effects after being vaccinated, with more pronounced discomfort after the second dose. The common side effects of COVID-19 Vaccine include: Headache, Muscle pain & Joint pain, Fatigue, Chills & Fever, Pain at injection site, Cough and possible severe Anaphylactic reaction such: skin rash/hives, nausea/ vomiting, SOB, chest pain, tachycardia, hypotension, tongue swelling, lightheadedness. Facility Staff will conduct covid-19 Vaccine screening prior to administration of the vaccine to ensure the resident meets criteria to receive the vaccine. The Vaccine Information Statement(s) is/are provided to you outlining the risks and benefits of the vaccine(s)being offered. We request that you read the information provided and ask your Director of Nursing or responsible nurse if you have any questions. To assure our ability to provide you or your loved one with the desired vaccinations(s), it is required that we retain a signed acknowledgement and Informed Consent (provided further below).

Please read attached PDF forms regarding vaccine information prior to signing.

Please print and sign form. Email ( or fax (818.348.1940) it back to us at your earliest convenience. 

Covid-19 Vaccine Informed Consent

Please fill out the electronic consent form below to avoid any delays in administering the vaccine to your loved one.

Thanks for submitting!

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