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Affidavit of Consent - Covid Vax

The document is an affidavit from an aunt and guardian consenting to her 15-year-old nephew receiving the Pfizer-BioNTech COVID-19 vaccine or other approved vaccines. She attests that she is authorized to provide medical consent for her nephew and understands the vaccine being administered is FDA approved for minors under Emergency Use Authorization.

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Kenny Robert's
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35 views1 page

Affidavit of Consent - Covid Vax

The document is an affidavit from an aunt and guardian consenting to her 15-year-old nephew receiving the Pfizer-BioNTech COVID-19 vaccine or other approved vaccines. She attests that she is authorized to provide medical consent for her nephew and understands the vaccine being administered is FDA approved for minors under Emergency Use Authorization.

Uploaded by

Kenny Robert's
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Republic 

of the Philippines)
City of Zamboanga          ) S.S.
X--------------------------------X
  
AFFIDAVIT

         I, _____________________________, of legal age, married, Filipino citizen and a resident


of Mampang, Zamboanga City, Philippines, after having been duly sworn to in accordance with
law, depose and state that:

1. I am the aunt and guardian of __________________, who is a 15 year old minor and
was born on February 19, 2006 to Spouses Noel Delos Reyes Baguio and Lea I.
Baguio, and who has been living under my care and custody for several years now;

2. By virtue of my aforementioned capacity, I am authorized to consent to the


inoculation of Pfizer-BioNTech-COVID-19 vaccine or other Covid-19 vaccines
intended for minors and other medical treatment for my afore-named nephew;

3. Thus, I hereby consent to the inoculation and administration of Pfizer-BioNTech-


COVID-19 vaccine or other Covid-19 vaccines intended for my minors, for my
nephew,______________________, by the qualified medical personnel and
understand that following to said vaccination, I will observe said child from time to
time for any adverse reaction and implement any supportive care measure to ensure
the successful immunization of said child;

4. Moreover, I understand that my afore-named nephew will receive a COVID-19


vaccine duly approved by the Food and Drug Administration under Emergency Use
Authorization intended for minors;

5. I execute this Affidavit to attest to the truth of the foregoing facts based on my
personal knowledge and authentic records for whatever legal purpose it may serve.

         IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of
___________________ at Zamboanga City, Philippines.

_________________________
Affiant

SUBCRIBED AND SWORN to before me on this ____ day of _________________ at


Zamboanga City, Philippines. Affiant having exhibited to me her Taxpayer’s Identification Card
numbered 408-381-442, issued by the Bureau of Internal Revenue at Zamboanga, Philippines.

Doc. No. _____;


Page No. _____;
Book No. _____;
Series of 2022

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