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Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.


Notice of Informed Consent

What is COVID-19?

COVID-19 is an infectious disease caused by a novel respiratory coronavirus. COVID-19 poses a serious public health risk and is highly contagious. For more information about the virus, please visit the CDC and/or WHO websites dedicated to this issue.

How would a COVID-19 vaccine work?

As with any vaccine, the goal of a COVID-19 vaccine is to expose the body to an antigen that won’t cause disease but will provoke an immune response that can block or kill the virus if a person becomes infected. Vaccines contain either the whole virus or a component. After receiving a vaccine, a person develops immunity to that disease without having to get the disease. The immunity varies based on the type of vaccine you receive.

Can I get Covid-19 from the vaccine?

The vaccine cannot give you Covid-19 because it is a killed virus vaccine. If you develop Covid-19 symptoms after the vaccine it may be that you have already been exposed to Covid-19 before receiving the vaccine. While the vaccine cannot stop Covid-19 once it has begun, it may make symptoms less severe. Some people do experience mild side effects. Most common is soreness in the vaccine site or possibly a mild fever. These side effects usually last only 24 hours. There is a possibility, as with any vaccine or drug, an allergic reaction or other serious reaction could occur. Moreover, untold medical events completely unrelated to the vaccine administration may occur coincidentally in the aftermath period following vaccination.

Is it safe to receive the vaccine?

The COVID-19 vaccination will be conducted in compliance with CDC’s Guidance for Immunization Services During the COVID-19 Pandemic for safe delivery of vaccines.

Pre-Vaccination Checklist Questions:

1. Are you feeling sick today?

2. Have you ever received a dose of the Covid-19 Vaccine? If so, which product: Pfizer, Moderna, other

3. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital?

4. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?

5. Have you received another vaccine in the last 14 days?

6. Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?

7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?

8. Do you have a bleeding disorder or are you taking a blood thinner?

9. Are you pregnant or breastfeeding?

If you answer “yes” to any question, it does not necessarily
mean you should not be vaccinated. It just means additional
questions may be asked. If a question is not clear, please ask
your healthcare provider to explain it.

RELEASE
I verify that I have been provided with and have read (or had read to me) the “FACT SHEET FOR RECIPIENTS AND CAREGIVERS – Emergency Use Authorization for the COVID-19 Vaccine" document included in the link below. I acknowledge that I have had a chance to ask questions of a medical professional about the Covid vaccine. I understand that the Covid vaccine will be given in two separate doses. I understand the known risks and the potential benefits of receiving the Covid vaccine, and I understand that there may be risks to the Covid vaccine that are not known at this time. I nonetheless request and consent to the Covid vaccine being given to me. I acknowledge that receipt of this vaccine is voluntary on my part and is provided at no charge to me. I agree to hold the County of Sonoma and its agents harmless from any injury or loss resulting from my receipt of the Covid vaccine.

I understand it is recommended that I remain on site for at least 15 minutes after receiving the Covid vaccine.


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