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    Congvax Consent Form

    Uploaded by

    Rico Maligaya
    This consent form provides information for receiving the Sinovac COVID-19 vaccine. It confirms that the recipient was informed of the vaccine's EUA status and screened for deferral conditions. It releases liability for adverse effects to the vaccine providers. It also details the recipient's rights to PhilHealth benefits if hospitalized for a serious adverse reaction. The recipient consents to personal data processing related to vaccine administration under the Data Privacy Act.

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    Congvax Consent Form

    Uploaded by

    Rico Maligaya
    149 views3 pages
    This consent form provides information for receiving the Sinovac COVID-19 vaccine. It confirms that the recipient was informed of the vaccine's EUA status and screened for deferral conditions. It releases liability for adverse effects to the vaccine providers. It also details the recipient's rights to PhilHealth benefits if hospitalized for a serious adverse reaction. The recipient consents to personal data processing related to vaccine administration under the Data Privacy Act.

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    This consent form provides information for receiving the Sinovac COVID-19 vaccine. It confirms that the recipient was informed of the vaccine's EUA status and screened for deferral conditions. It releases liability for adverse effects to the vaccine providers. It also details the recipient's rights to PhilHealth benefits if hospitalized for a serious adverse reaction. The recipient consents to personal data processing related to vaccine administration under the Data Privacy Act.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    149 views3 pages

    Congvax Consent Form

    Uploaded by

    Rico Maligaya
    This consent form provides information for receiving the Sinovac COVID-19 vaccine. It confirms that the recipient was informed of the vaccine's EUA status and screened for deferral conditions. It releases liability for adverse effects to the vaccine providers. It also details the recipient's rights to PhilHealth benefits if hospitalized for a serious adverse reaction. The recipient consents to personal data processing related to vaccine administration under the Data Privacy Act.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 3

    CONSENT AND WAIVER FORM

    Name: Birthdate: Sex:


    Address:
    Occupation: Contact Number:
    Health Facility:

    I confirm that I have been provided with adequate


    information about the Sinovac COVID-19 vaccine and its
    Emergency Use Authorization (EUA) from the Philippine
    Food and Drug Administration.

    I confirm that I have been screened for conditions that


    may merit deferment or special precautions during
    vaccination as indicated in the Health Screening
    Questionnaire.

    I have received sufficient information on the benefits and


    risks of COVID-19 vaccines and I understand the
    possible risks if I am not vaccinated.

    I was provided an opportunity to ask questions, all of


    which were answered and explained to me adequately
    and clearly. I, therefore, voluntarily release the House of
    Representatives, the vaccine manufacturer, their agents
    and employees, as well as the hospital, the medical
    doctors and vaccinators, from all claims relating to the
    results of the use and administration of, or the
    ineffectiveness of the Sinovac COVID-19 vaccine.

    I understand that while most side effects are minor and


    resolve on their own, there is a small risk of severe
    adverse reactions, such as, but not limited to allergies.
    Should the need for prompt medical attention arise,
    referral to the nearest hospital shall be provided
    immediately by the House of Representatives. I have
    been given contact information for follow up for any
    symptoms I may experience after vaccination.

    I understand that in case I suffer a serious adverse


    event, which is found to be associated with the Sinovac
    COVID-19 vaccine or its administration, I have a right to
    health benefit packages under the Philippine Health
    Insurance Corporation (PhilHealth) program in case I
    experience hospitalization due to severe and/or serious
    adverse reactions.

    “Pursuant to Republic Act No. 10173, the Data Privacy


    Act of 2012, and its Implementing Rules and
    Regulations, I have been informed of the purpose of the
    collection of personal data, the extent of its processing,
    the automated manner of processing of the personal
    data for profiling or data sharing, the identity/ies of the
    data processor/s who will be given access to the
    personal data, and my rights as a data subject.

    I agree to the collection and processing of personal,


    sensitive personal, or privileged information to be
    conducted by the HREP and DOH Personal Information
    Controllers and Personal Information Processors, with
    the end in view of safeguarding the collected personal
    data as well as ensuring and maintaining the
    confidentiality, integrity and availability of the said
    personal data or information.

    Consequently, I reasonably presume that the HREP and


    DOH will protect the collected data against natural
    dangers such as accidental loss or destruction,
    unauthorized access, fraudulent misuse, alteration and
    contamination.

    The consent I have given for the processing of data shall


    be limited only for the purpose of the administration of
    the COVID-19 vaccine.

    I hereby give my consent to be vaccinated with the


    Sinovac COVID-19 Vaccine.

    _________________________ ____________
    Signature Over Printed Name Date
    In case eligible individual is unable to sign:
    I have witnessed the accurate reading of the consent
    form and liability waiver to the eligible individual;
    sufficient information was given and questions raised
    were adequately answered. I hereby confirm that he/she
    has given his/her consent to be vaccinated with the
    Sinovac COVID-19 Vaccine.

    ________________________ ____________
    Signature Over Printed Name Date
    Relationship to the principal ______________________

    If you choose not to get vaccinated, please list down


    your reason/s

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