COVID-19 Vaccine Consent Process

The pandemic has been extremely stressful for our residents, caregivers, and staff. Williamsburg Village is excited to announce the selection of Walgreens to serve as our healthcare partner in administering the Pfizer-BioNTech COVID-19 vaccine. Trained Walgreens pharmacists and immunization technicians will be doing the injections onsite and at no cost to the recipient.

We are working hard to protect our residents and staff as we continue to fight this pandemic – and soon, we’ll take a huge step forward with onsite COVID-19 vaccines.

As a standard procedure, individual consent must be given before every vaccination. However, on the behalf of patients with dementia and other cognitive challenges, family caregiver consent forms are now available for download and from the front desk during normal business hours.

And while we do not yet have the vaccine, we do need to be prepared for when we do receive it. We ask that all caregiver consent forms be returned to us as soon as possible by U.S. Mail or hand delivered to the front desk. You may also fax it to: 972-572-9365, or send it by email to: ExecutiveDirector@wvsnf.com & DON.york@wvsnf.com. We anticipate being able to begin the resident vaccinations the week of December 28, 2020.

The CDC and a preponderance of physicians and scientists are strongly recommending that all Americans, particularly those considered high risk, take the vaccine as it is an important tool in stopping the spread of COVID-19.

If you have any questions or concerns, please do not hesitate to contact us.

COVID-19 Vaccine Consent FAQ

No. The Pfizer-BioNTech COVID-19 Vaccine does not contain SARS-CoV-2 and cannot give you COVID-19.

When a person receives this vaccine, their body produces copies of the spike protein, which does not cause disease, but triggers the immune system to react defensively, producing an immune response against SARS-CoV-2. The vaccine will be given as a series of two injections into a muscle. The second dose given three weeks later.

Trained Walgreens pharmacists and immunizing technicians will be doing the injections onsite and at no cost to the recipient.

It is your choice to permit or to not permit the incapacitated resident to receive the Pfizer-BioNTech COVID-19 Vaccine. It will not change their standard medical care.

If a person with dementia is able to make the decision for themselves, they can choose whether to have the vaccine or not. They just need to give informed consent to do so – the same as for any medical procedure. That decision is theirs to make and will be respected.

Source: The Centers for Disease Control & Prevention
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Image: COVID Vaccine

Informed Consent Form Instructions

Please complete following sections:

  • Section A-1 (Demographics)
  • Section A-2 (Consent)
  • Section B-1 (Screening Questions)
  • Section B-2 (Name & Date)
  • Section C (Insurance — if applicable)

Please leave sections D through F blank. Healthcare personnel will complete these sections prior to administering the vaccination.

Additional Resources

    • What to Expect — we understand that some may feel hesitant about getting the novel COVID-19 vaccine. This handout provides additional information about the vaccine and the process.