INFORMED CONSENT FORM FOR THE SINOVAC COVID-19 VACCINE
of the Philippine National COVID-19 Vaccine Deployment and Vaccination Program
as of March 5, 2021
Name: Birthdate: Sex:
Address:
Occupation: Contact Number:
Health facility:
INFORMED CONSENT
I confirm that I have been provided with adequate (PhilHealth) program in case I experience
information about the donated SINOVAC COVID-19 hospitalization due to severe and/or serious
vaccine, its Emergency Use Authorization from the adverse reactions.
Philippine Food and Drug Administration with
advice for healthcare workers directly exposed to I authorize releasing all information needed for
COVID-19 patients and those with comorbidities, public health purposes including reporting to
and the recommendations of the interim National applicable national vaccine registries, consistent
Immunization Technical Advisory Group in the with personal and health information storage
absence of any other vaccine to provide workers in protocols of the Data Privacy Act of 2012.
frontline health services the autonomy to decide to
be vaccinated with this specific batch of donated I hereby give my consent to be vaccinated with the
SINOVAC vaccines without prejudice to immediate SINOVAC COVID-19 Vaccine.
eligibility for other vaccines. 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.
Signature over Date
I confirm that I have been screened for health Printed Name
conditions that may merit deferment or special
precautions during vaccination as indicated in the
Health Screening Questionnaire. In case eligible individual is unable to sign:
I have witnessed the accurate reading of the
I was provided an opportunity to ask questions, all consent form and liability waiver to the eligible
of which were adequately and clearly answered. I, individual; sufficient information was given and
therefore, voluntarily release the Government of the queries raised were adequately answered. I
Philippines, the vaccine manufacturer, their agents hereby confirm that he/she has given his/her
and employees, as well as the hospital, the medical consent to be vaccinated with the SINOVAC
doctors and vaccinators, from all claims relating to COVID-19 Vaccine.
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 Signature over Date
severe adverse reactions, such as, but not limited Printed Name
to allergies, and that should prompt medical
attention be needed, referral to the nearest hospital If you chose not to get vaccinated, please list
shall be provided immediately by the Government
down your reason/s:
of the Philippines. 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
