COVID-19 Vaccine Information and Consent Form

COVID-19 VACCINE FACT SHEET

You are being offered a COVID-19 Vaccine against Coronavirus Disease 2019 (COVID-19) caused by SARS-CoV-2. This fact sheet intends to help you understand the benefits as well as the risks of the vaccine.

The COVID-19 vaccine is administered in two separate doses, one month apart. 

WHO CAN GET THE COVID-19 VACCINE?
Any person aged 18 years or older is allowed to receive the COVID-19 vaccine.

PERSONS WHO SHOULD NOT RECEIVE COVID-19 VACCINE:
As much as we would like everyone to be immunized, there are certain prohibitions. In case a person has had severe allergic reaction after a previous dose of this vaccine should refrain from receiving further vaccination, or those who have severe allergic reaction to any of the ingredients found in the vaccine.

THE INGREDIENTS:
The Moderna vaccine contains the following:

1. messenger ribonucleic acid (mRNA);
2. lipids
   1. SM-102,
   2. polyethylene glycol [PEG] 2000 dimyristoyl glycerol [DMG],
   3. cholesterol,
   4. 1,2-distearoyl-sn-glycero-3-phosphocholine [DSPC],
3. tromethamine
4. tromethamine hydrochloride
5. acetic acid
6. sodium acetate
7. sucrose

The Pfizer-BioNTech vaccine contains the following:

1. mRNA,
2. lipids ((4-hydroxybutyl)azanediyl)bis(hexane-6,1-diyl)bis(2-hexyldecanoate), 2
   [(polyethylene glycol)-2000]-N,N-ditetradecylacetamide, 1,2-Distearoyl-sn-glycero-3-phosphocholine, and cholesterol),
3. potassium chloride
4. monobasic potassium phosphate
5. sodium chloride
6. dibasic sodium phosphate dihydrate
7. sucrose

WHAT SHOULD THE DOCTOR OR MEDICAL STAFF ADMINISTERING THE VACCINE KNOW FROM YOU:
They should know your medical conditions, including:

1. Your known allergies or food which you are allergic to;
2. Whether you have any of the symptoms of COVID-19;
3. Whether you have a bleeding disorder or you are taking any blood thinners;
4. Whether you are immunocompromised or under medication that affects your body's immune system.
5. Whether you are pregnant, breastfeeding or you plan to become pregnant
6. Whether you have received a COVID-19 vaccine previously and what manufacturer.

HOW IS COVID-19 VACCINE ADMINISTERED?
The vaccine shall be given in 2 doses, 1 month apart or with a gap of 4 weeks, and shall be done by injecting it into the muscle. 

ARE THE VACCINES APPROVED BY THE FDA?
The Moderna COVID-19 Vaccine is currently an unapproved vaccine and is still undergoing clinical trials, approximately 15,400 individuals 18 years of age and older have received at least 1 dose of the Moderna COVID-19 Vaccine. Currently, it is approved only for emergency purposes.

Pfizer-BioNTech COVID-19 Vaccine on the other hand has been given authorization by the FDA to prevent coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in individuals 16 years of age and older.

WHAT ARE THE RISKS OF COVID-19 VACCINE?
Some of the reported side effects of having injected with the vaccine include pain, tenderness, and swelling of the lymph nodes, redness, muscle pains, joint pains, fatigue, chills, nausea, fever, and vomiting. There have been cases of persons having allergic reactions to the vaccine which occurs usually a few minutes after getting a dose. For this reason why it is recommended that individuals injected should remain for at least 15 - 30 minutes after receiving the vaccine in order to be monitored for any allergic reactions. 

The following allergic reactions may include:
• Difficulty breathing
• Swelling of your face and throat
• A fast heartbeat
• A bad rash all over your body
• Dizziness and weakness

You may be given an opportunity to enroll in v-safe to monitor your condition after vaccination through online and text messaging. V-safe is a smartphone-based tool that checks in with people who have been vaccinated to monitor an individual's status and help identify the potential side effects of the vaccination. This tool also helps as a reminders for follow-up on the second dose of the vaccine. Please visit this link for more information: www.cdc.gov/vsafe.

WHAT SHOULD I DO ABOUT SIDE EFFECTS?
If you feel or start to experience any severe allergic reaction, please call 9-1-1, contact your physician, and go to the nearest hospital.

You can submit a report about the side effects of the vaccine injected to you to the FDA/CDC Vaccine Adverse Event Reporting System (VAERS). You can fill-up the form on the website through this link: https://vaers.hhs.gov/reportevent.html, or call their toll-free number at 1-800-822-7967.

WHAT IF I CHOOSE NOT TO GET A COVID-19 VACCINE?
Nothing will change in the medical care that you should receive. It is your choice not to receive the vaccine.

ARE ANY OTHER OPTIONS IN PREVENTING FROM BEING INFECTED WITH COVID-19?
There is no other approved medical alternative in preventing infection from COVID-19.  

CAN I RECEIVE TWO DIFFERENT VACCINES?
There is no supporting information that this method is dangerous, nor safe.

ARE BREASTFEEDING MOTHERS OR PREGNANT WOMEN ALLOWED TO BE VACCINATED?
It is best to discuss this with your physician or your healthcare provider.

WILL THE VACCINE INFUSE ME WITH COVID-19?
No. The vaccine does not contain any virus nor can it give you COVID-19.

WHAT DO I DO WITH THE VACCINATION CARD?
After receiving your first dose of the vaccine, you will be given a vaccination card. Keep it as a reminder that you will need to have your second dose. Bring it with you for your second dose.