Form 14414 MS 2017-2025

Form 14414 MS: What You Should Know

How to fill out Pfizer-BioNTech COVID-19 Vaccine EUA LOA? Use the following template (and do not use an official form). Dear ___________, I have read the information that appears below, and have decided to register to fill out the form (in accordance with the instructions on the form). This form is part of an ongoing study by Pfizer-Bio-NTech for the treatment of acute myeloid leukemia, an incurable blood cancer, as part of the Pfizer-Bio-NTech-COVID/European Osteosarcoma and Bone Marrow Transplant Study (or COVID-19) ___________. If I sign below, I will be providing the following information for the study, and I hereby consent: 1. Name 2. Street Address 3. City 4. State/Province/Country 5. Zip/Postal Code 6. Telephone number, including extension 7. Mobile phone, if applicable 8. Email address 9. I agree to receive periodic updates by email from Pfizer-Bio-NTech including any news and materials relating to the study, and I understand that I may discontinue my participation at any time. I consent to Pfizer-Bio-NTech/ European Osteosarcoma and Bone Marrow Transplant Study (or COVID-19) or its successor. By filling out this form, I have indicated agreement, without limitation, to these terms and conditions, including any additional terms that may be provided with or posted about my use of this form. I understand that I may discontinue my participation at any time. I agree to accept compensation from Pfizer-Bio-NTech/ European Osteosarcoma and Bone Marrow Transplant Study (or COVID-19) or its successor for participation in the study, subject to reimbursement as appropriate. Furthermore, I also agree to be bound by the terms and conditions of this form and agree the materials accompanying this form are not to be furnished, reproduced, disseminated, or distributed to anyone who has not consented to them, and I understand that I may take no further action with regard to the information provided or any materials that accompany this form. Furthermore, I consent to Pfizer-Bio-NTech/ European Osteosarcoma and Bone Marrow Transplant Study (or COVID-19) or its successor continuing clinical studies, research projects and other programs related to the study.

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