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　　接種新型冠狀病毒疫苗免責(zé)承諾書

　　本人 ，性別 ，出生于 年 月 日，護(hù)照號(hào)碼(或中國(guó)永久居留身份證號(hào)) 。本人已認(rèn)真閱讀新型冠狀病毒疫苗接種知情同意書，認(rèn)同上述文件內(nèi)容，自愿、自費(fèi)接種新型冠狀病毒疫苗，承諾向接種現(xiàn)場(chǎng)工作人員如實(shí)告知本人的健康狀況和接種禁忌等情況。本人已清楚了解疫苗的品種、作用、禁忌以及接種疫苗可能導(dǎo)致的不良反應(yīng)，對(duì)選擇接種疫苗引起的一切風(fēng)險(xiǎn)完全由本人自行承擔(dān)。

　　本人姓名(印刷體)： 本人簽名：

　　日期：2021年 月 日

　　Letter of Commitment on Receiving

　　Inactivated SARS-CoV-2 Vaccine

　　I , (Name), (Gender),born on (Year-Month-Date).The number of my passport (or foreign permanent resident ID card) is .I have read letter of consent. I acknowledge the content of the abovementioned documents, consent to voluntary vaccination and will pay for all relevant expenses. I promise to truthfully inform health workers on site of my personal information such as health conditions and vaccine contraindications. I am fully aware of the type, usage of the vaccine and its contraindications, as well as the possible adverse reactions after vaccination. All risks associated with vaccination shall be borne entirely by myself.

　　Name(in print): Signature:

　　Date: (Day) (Month)2021