Mid Land Exams

Minor Vaccination Authorization

Minor Vaccination Authorization

Authorization to Administer COVID-19 Vaccine in Absences of Parent/Legal Guardian

To the J&K Healthy Choice and its affiliates, vaccine appointment and authorize J&K Healthy Choice to administer the COVID-19 vaccine to my child in my absence

I GIVE CONSENT for the child named at the top of this form to get vaccinated with the COVID-19 Vaccine and reviewed and agree to the information

Name of the Parent or Legal Guardian

For 12- through 15-years-olds who will not be accompanied by their parent or legal guardian only

If you check this box, you may be asked to attest to this at your vaccine appointment