COVID-19 VACCINE SCREENING AND CONSENT FORM Pfizer …

September 28, 2021

Page 1 of 2 Pfizer-BioNTech COVID-19 Vaccine Effective Date: 12/13/2020 … Have you had a severe allergic reaction to a previous dose of this vaccine or to any of the ingredients of this vaccine? 3. Do you carry an Epi-pen for emergency treatment of anaphylaxis? 4. For women, are you pregnant or is there a chance you could become pregnant?

http://leon.floridahealth.gov/_files/_documents/pfizer-screen-consent-form.pdf

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