• Guthrie County Health Care Covid-19 Vaccine Consent/Decline

    Please Read the Covid-19 EUA fact sheet and fill out this form to reserve a Covid-19 Vaccination or to decline vaccination.
    • Click to Open and Read MODERNA COVID 19 EUA 
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  • Vaccine Consent 

    I have read or have had explained to me the information provided in the Emergency Use Authorization (EUA) Factsheet or Vaccine Information Statement about COVID-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of COVID-19 vaccine and ask that the vaccine be administered to me.

     

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    • FOR CLINICIAN USE ONLY 
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  • Vaccine Decline

    I have read or have had explained to me the information provided in the Emergency Use Authorization (EUA) Factsheet or Vaccine Information Statement about COVID-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of COVID-19 vaccine and ask that the vaccine not be administered to me.

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