接种新型冠状病毒疫苗免责承诺书

　　本人 ，性别 ，出生于 年 月 日，护照号码(或中国永久居留身份证号) 。本人已认真阅读新型冠状病毒疫苗接种知情同意书，认同上述文件内容，自愿、自费接种新型冠状病毒疫苗，承诺向接种现场工作人员如实告知本人的健康状况和接种禁忌等情况。本人已清楚了解疫苗的品种、作用、禁忌以及接种疫苗可能导致的不良反应，对选择接种疫苗引起的一切风险完全由本人自行承担。

　　本人姓名(印刷体)： 本人签名：

　　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