Have You Actually Read A COVID19 Vaccine Consent Form Yet? Here’s One …

Have You Actually Read A COVID19 Vaccine Consent Form Yet?

Very few of us take the time to read the small print when we buy many products and services. It’s the same with our vaccine shots. Otherwise, if we did take a couple of minutes to diligently read what vaccine companies admit they are doing to our bodies, fewer of us would permit ourselves to endure this insanity.

Below is a sample vaccine consent form from INOVA. Inova Health System is a non-profit health organization based in Falls Church, Virginia, near Washington, D.C. The system is a network of hospitals, outpatient services, assisted living and long-term care facilities, and healthcare centers.


Typical of most organizations that provide COVID19 vaccines, here is what they say in their vaccine consent form:

“I declare that I or my child is 16 years of age or older. I further declare that I or my child:

  1. Have not experienced anaphylaxis (difficulty breathing) or severe allergic reactions from a previous vaccination or an injectable medication.
  2. Have not had any other vaccinations in the previous 14 days (e.g. MMR, Shingrix, Varicella, or a TB skin test).
  3. Is not currently sick with a fever, active respiratory infection or other moderate/severe illness.
  4. Has have not received monoclonal antibodies or convalescent plasma for treatment of COVID-19 within the past ninety (90) days.
  5. Is not allergic to the following ingredients in the COVID-19 vaccine: mRNA, lipids((4-hydroxybutyl)azanediyl)bis(hexane-6, 1-diyl)bis(2-hexyldecanoate), 2[(polyethylene glycol)-2000]-N, N-ditetradecylacetamide, 1, 2-Distearoyl-sn-glycero-3-phosphocholine, and cholesterol), potassium chloride, monobasic potassium phosphate, sodium chloride, dibasic sodium phosphate dihydrate and sucrose.

I understand that if I or my child have any of the above conditions, I or my child could be at increased risk of having a negative reaction or problem from the vaccine.

I further declare that if I or my child have any of the following conditions, I have had the opportunity to speak with my or my child’s primary care provider and am making an informed decision to receive the vaccine or to have my child receive the vaccine:

  1. Pregnant, attempting to become pregnant or breastfeeding;
  2. Have a bleeding disorder or are on a blood thinner;
  3. Are immunocompromised or are taking a medication that affects the immune system (such as cortisone, prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease or psoriasis; HIV/AIDS, cancer, leukemia, ankylosing spondylitis or radiation treatments).

I agree to WAIT near the clinic location for 15 minutes after receiving the vaccine. If I or my child have previously had a severe allergic reaction to a vaccine or injectable medication, I agree to WAIT near the clinic location for 30 minutes after receiving the vaccine.

I understand that the COVID-19 vaccine is a two-part vaccine series. By signing this consent, I am agreeing that I or my child will receive the first and second part of the vaccine series.

I understand that the common risks associated with the COVID-19 vaccine include but are not limited to pain, redness or swelling at the site of injection, tiredness, headache, muscle pain, chills, joint pain, fever, nausea, feeling unwell or swollen lymph nodes (lymphadenopathy). I understand that the vaccine may cause a severe allergic reaction which can include anaphylaxis (difficulty breathing, swelling of the face and throat, a fast heartbeat, a rash all over the body, dizziness and/or weakness).

I understand that these may not be all the side effects of the COVID-19 vaccine as the vaccine is still being studied in clinical trials. I also understand that it is not possible to predict all possible side effects or complications which could be associated with the vaccine. I understand that the long-term side effects or complications of this vaccine are not known at this time. [emphasis added]

I understand that the vaccination is being given by Inova Health System Foundation and its affiliates (collectively Inova). The owner and/or operator of this site, their affiliates, officers, directors, employees and agents expressly disclaim any responsibility for the vaccination.

My consent is given in light of this knowledge, and in consideration of Inova giving the COVID-19 vaccine. I, for myself and my heirs, administrators, trustees, executors, assigns and successors in interest do hereby agree to release and hold harmless Inova, its subsidiaries, divisions, affiliates, successors, assigns, officers, trustees, employees, volunteers and agents from and against any and all demands, damages, losses, costs, expenses, obligations, liabilities, claims, actions and cause of action (whether any of which is groundless or otherwise) of any nature whatsoever (including, without limitation, reasonable attorney’s fees and court costs) by reason of or resulting, in any way, from any and all acts, accidents, events, occurrences, omissions and the like related to, or arising out of, directly or indirectly, my receipt of this COVID-19 vaccine.

[emphasis added]

Inova makes no warranties, express or implied, including but not limited to, implied warranties of merchantability or fitness for a particular purpose regarding the vaccine or its effectiveness.

I acknowledge receipt of Inova’s Notice of Privacy Practices.

Medicare Part B Recipients: I understand Inova will process Medicare Part B claims on my behalf and accepts Medicare payment in full. I understand I must present my Medicare card prior to receiving the vaccine. I understand that if I have assigned my Medicare benefits to a Medicare Advantage Plan (like an HMO or PPO), I must receive my COVID-19 vaccine shot from my HMO/managed care provider or pay the Inova charge.

Private Insurance Participants: If I have private insurance, I understand that Inova will not bill my insurance carrier on my behalf, and that I am responsible for paying the required fee for this vaccine to Inova and for pursuing reimbursement from my health insurance carrier. Inova cannot guarantee that this service will be reimbursable by insurance.

I have read and understood “What To Do If You Have A Reaction To The COVID-19 Vaccination” and the “Fact Sheet” by the FDA regarding the COVID-19 Vaccination. I further understand and agree that Inova is required to submit COVID-19 vaccine administration data to the Virginia Immunization Information System (VIIS), and report moderate and severe adverse events following vaccination to the Vaccine Adverse Event Reporting System (VAERS).

I understand and agree to all of the above and I hereby give my consent to the staff of Inova to give me or my child a COVID-19 vaccine.”

Read the full INOVA document here: COVID-19 Vaccine Consent Form – Inova

Remember, folks, you have been warned!



About John O’Sullivan John is CEO and co-founder (with Dr Tim Ball) of Principia Scientific International (PSI).  John is a seasoned science writer and legal analyst who assisted Dr Ball in defeating world leading climate expert, Michael ‘hockey stick’ Mann in the ‘science trial of the century‘. O’Sullivan is credited as the visionary who formed the original ‘Slayers’ group of scientists in 2010 who then collaborated in creating the world’s first full-volume debunk of the greenhouse gas theory plus their new follow-up book.

Published to The Liberty Beacon from EuropeReloaded.com


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