The Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on Immunization Practices (ACIP) recommends the U.S. FDA’s amended Emergency Use Authorization of the Pfizer COVID-19 vaccine for ages 5-11. The CDC has also authorized pediatric COVID-19 vaccine for children 5 to 11 years old.
Based on those recommendations, the Indiana Department of Health supports the administration of pediatric doses to individuals who attest to meeting CDC guidelines. The vaccine is now available to protect more than 610,000 young Hoosiers against COVID-19.
Anyone 5 and older is now eligible to receive the Pfizer Covid-19 vaccine. A parent needs to be present for anyone 5–18-years old. If this is not an option, you MUST complete the CONSENT FOR COVID-19 VACCINATION FORM attached below. A copy of a parent’s ID and insurance card must be included.
Starting November 4, 2021, you can visit www.ourshot.in.gov to schedule a pediatric appointment or call 211 for assistance.
Our drive-thru is only available to those 12 years of age and older.
Please be aware, we will not have pediatric (5-11 y/o) Covid-19 vaccine available at this Saturday’s Covid-19 booster clinic on November 6, 2021, from 8:00am -12:00pm.
CONSENT FOR COVID-19 VACCINATION<18 years
Complete the following for the person who is being vaccinated:
Name: First ________________ Middle ______________ Last_________________ DOB: ____________
Sex: M/F (Circle)Mailing Address: ___________________________________________________
Parents/Guardian Full Name: __________________________ Phone Number:_______________
Ethnicity: Hispanic/Non-Hispanic (circle)
Race: American Indiana/ Alaskan Native, Asian, Black, Native Hawaiian/Pacific Islander, White, Unknown (circle all that apply)
Insurance Status:
□ No insurance□ Medicaid (please provide RID number) ______________________________
□Private or commercial Insurance (Not Medicaid)
Insurance Company_________________ Insurance Policy ID ______________
Group # ____________________ Policy Holders name: ________________
Policy Holders DOB: ___________________Policy Holders relationship to patient: _______________
Questions for person getting vaccinated:
| Questions | Yes or no | If yes, explain |
| Is the person to be vaccinated sick today? | ||
| Does the person being vaccinated have any allergies to medications foods, a vaccine component or latex? | ||
| Has the person to be vaccinated ever had a serious reaction to a vaccine in the past? | ||
| Has the person being vaccinated ever had Guillain-Barre Syndrome | ||
| If the person to be vaccinated pregnant or is there a chance they could become pregnant? |
By signing below, I consent to the use and disclosure of my or my child’s personal health information for the purpose of health care operations, along with the assignment of all payments from the insurer listed above to Indiana Department of Health (IDOH) for the services rendered.
Consent for use of protected health information and claims assignment: I hereby consent to and acknowledge the receipt of a Notice of Privacy Practices regarding the use and disclosure of my personal health information for the purpose of health care operations, along with the assignment of all payment from the insurance provider (if applicable) to IDOH for administration for the COVID-19 vaccination.
Vaccine authorization: My signature on this form indicates that I have requested that the COVID_19vaccine be administered to me or my dependent by a vaccination clinic representative. I acknowledge that I have received information concerning the risks and benefits of the COVID-19 vaccine and that I have had a chance to ask questions that were answered to my satisfaction (you can call 812-481-7056 with questions). I believe I understand the risks and benefits of the COVID 19 vaccine and consent to the administration of the vaccine to me or my dependent.
Signature of Parent or Guardian ____________________ Date: _________________
A COPY OF A PARENT’S ID AND INSURANCE CARD MUST BE PROVIDED
