Watsons Vaccination

Did you experience any allergic or adverse reaction after receiving Covid-19 primary doses?

YES NO

Did you receive any vaccines within 14 days?

YES NO

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Personal Information

*First name

Middle name

*Last name

*Birthdate

*Contact No. (ex. 09xxxxxxxxx)

*Email

*Address

*First Dose

*First Dose Vaccine

*Priority Group

*Second Dose

*Second Dose Vaccine

Confirmation

Basic Information

Name:

Birthdate:

Email:

Contact no:

Address:

First Dose Date:

First Dose Vaccine:

Second Dose Date:

Second Dose Vaccine:

Priority Group:

Date and Time scheduled

Date:

Time:

Branch:

I confirm that I have been provided with and have read the COVID-19 Vaccine Moderna / Pfizer-BioNTech / AstraZeneca / Sinovac Emergency Use Authorization (EUA) Information Sheet and the same has been explained to me. The FDA has amended the Emergency Use Authorization for these COVID-19 Vaccines to allow its use as additional/booster dose for specific populations in light of new scientific evidence.

I confirm that I have been screened for conditions that may merit deferment or special precautions for additional/booster dose vaccination as indicated in the Health Screening Questionnaire.

I have received sufficient information on the benefits and risks of receiving a additional/booster dose of the COVID-19 vaccine and I understand the possible risks if I am not vaccinated with an additional/booster dose.

I was provided an opportunity to ask questions, all of which were adequately and clearly answered. I, therefore, voluntarily release the Government of the Philippines, the vaccine manufacturer, their agents and employees, as well as the hospital, the medical doctors and vaccinators, from all claims relating to the results of the use and administration of, or the ineffectiveness of a additional/booster dose of COVID-19 vaccines.

I understand that while most side effects are minor and resolve on their own, there is a small risk of severe adverse reactions, such as, but not limited to allergies and blood clots associated with low platelet counts (vaccine-induced thrombotic thrombocytopenia), heart conditions (e.g. myocarditis and pericarditis) and that should prompt medical attention be needed, referral to the nearest hospital shall be provided immediately by the Government of the Philippines. I have been given contact information for follow up for any symptoms which I may experience after vaccination.

I understand that by signing this Form, I have a right to health benefit packages under the Philippine Health Insurance Corporation (PhilHealth), in case I suffer a severe and/or serious adverse event, which is found to be associated with these COVID-19 vaccine or its administration. I understand that the right to claim compensation is subject to the guidelines of the PhilHealth.

I authorize releasing all information needed for public health purposes including reporting to applicable national vaccine registries, consistent with personal and health information storage protocols of the Data Privacy Act of 2012.

I hereby give my consent to receive an additional/booster dose of the COVID-19 Vaccine Moderna / Pfizer-BioNTech / Sinovac / AstraZeneca.

I hereby certify that all above information are true.

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Health Declaration