• COVID-19 Vaccine Patient Intake Form

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  • Due to mandate by the U.S. CDC and FDA, we are unable to provide the Johnson & Johnson vaccine for in-home visits until further notice. Please refer to CDC.gov for more information. We appreciate your patience as we navigate this uncertain time. 

  • COVID-19 Questions

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  • CONSENT FOR SERVICES - I have been provided with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) that I am receiving. I have read the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccination and I voluntarily assume full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored for any potential adverse reactions and 30 minutes if you have a history of anaphylaxis. I understand if I experience side effects that I should do the following: call pharmacy, contact doctor, call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request. I do hereby authorize Ready Nursing Solutions Inc. to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or the HRSA COVID-19 Program for Uninsured Patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.
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  • DISCLOSURE OF RECORDS: I understand that Ready Nursing Solutions Inc, may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at Ready Nursing Solutions (if applicable), my Primary Care Physician (if I have one), my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or other health care operations (such as administration or quality assurance). I also understand that Ready Nursing Solutions Inc, will use and disclose my health information as set forth in the Ready Nursing Solutions Inc Notice of Privacy Practices that is available by requesting a paper copy. If I am receiving a vaccine through a vaccine clinic, I understand that my name, vaccine appointment date and time will be provided to the clinic coordinator.

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