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Covid 19 Self Declaration Form

COVID-19 Self Declaration Form

A COVID-19 self-declaration form is completed by patients to declare their interest in getting the COVID-19 vaccine. No coding!

Page 1

Please fill out the following information to declare your interest in getting the COVID-19 vaccine.

Email*

Full Name*

Date of Birth*

Phone Number*

Address*

City*

State*

Zip Code*

Have you been diagnosed with COVID-19?*

10.

Have you received a COVID-19 vaccine before?*

Description:Complete a COVID-19 self-declaration form with ease. Declare your interest in getting the COVID-19 vaccine without any coding!

The COVID-19 pandemic has affected the world in unprecedented ways. As the world continues to grapple with the pandemic, getting vaccinated is one of the most effective ways to protect yourself and others. This COVID-19 self-declaration form is designed to help patients declare their interest in getting the COVID-19 vaccine. With this form, patients can easily declare their interest in getting vaccinated without any coding. The form is easy to use and can be completed in a matter of minutes. By using this form, patients can help healthcare providers better understand the demand for the COVID-19 vaccine and ensure that everyone who wants to get vaccinated can do so.

Full Name*

Date of Birth*

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Consent to Treatment*

I have read and understand the information provided about the surgery and the risks involved.

I have had the opportunity to ask questions and have received satisfactory answers.

I understand that I may withdraw my consent at any time.

Consent to Anesthesia*

I have read and understand the information provided about the anesthesia and the risks involved.

I have had the opportunity to ask questions and have received satisfactory answers.

I understand that I may withdraw my consent at any time.

Consent to Blood Transfusion

I consent to the use of blood or blood products if needed during the surgery.

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