Individuals must complete a vaccine screening and consent form to confirm eligibility. Where to Go. The Florida Department of Health has published a form for physicians to certify that they have determined an individual to be extremely vulnerable to COVID-19 and eligible to receive the vaccine. least 16 years of age; or (c) authorized to consent for vaccination for the patient named above. Administration Facility Name/Facility ID: _____ 1. 850-674-5645 All Locations. Skip MegaMenu and goto content. All individuals under the age of 18 receiving a vaccine must be accompanied by a guardian and complete the COVID-19 vaccine screening and consent form. Only the vaccine produced by Pfizer-BioNTech is available to people under 18. In New York, where Democrats rule, they are seen as an important tool. The forms can be read and printed by clicking the links below. Please review the forms below before your vaccination appointment. COVID-19 VACCINE SCREENING AND CONSENT FORM. COVID FORMS. Page 1 of 2 Pfizer-BioNTech COVID-19 Vaccine Effective Date: 12/13/2020 COVID-19 VACCINE SCREENING AND CONSENT FORM ... personal immunization information in Florida SHOTS and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies. DOH COVID-19 Vaccination Consent Form COVID-19 VACCINE SCREENING AND CONSENT FORM Administration Facility Name/Facility ID: FDOH-St. Lucie SECTION 1: INFORMATION ABOUT PATIENT (PLEASE PRINT) Name: Last: First: Middle Initial: Date of Birth: Month Day Year Mobile Phone Number (Patient or Guardian): ( ) Effective Monday, April 5th, anyone over the age of 18 in the state of Florida is eligible to register for the COVID-19 vaccine. ... personal immunization information in Florida SHOTS and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies. Use this Florida form to get a coronavirus vaccine. Click here for COVID forms. Governor Ron DeSantis has signed Executive Order 21-79 (Effective March 29, 2021) which amends Executive Order 21-67 outlining that providers can only administer the COVID-19 vaccine to the following populations: Lee County Vaccination Site - … The Florida Department of Health in Lee County (DOH-Lee) is offering COVID-19 vaccine to the following groups: Long-term care facility residents and staff; ... you can print and complete the FDOH vaccine screening and consent form before you arrive. In Florida, the state’s Republican Governor has banned any form of vaccine passport. Please print and complete the Screening and Consent Form before your appointment, if possible: Screening and Consent Form (PDF 128 KB) Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. Florida releases COVID vaccine form for ‘extremely vulnerable’. COVID-19 Call Center available 24/7 | +1 (866) 779-6121 or email COVID-19@flhealth.gov. 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