Section I. Appointment Scheduler
Section II. Personal Information
Section III. Questionnaire for Immunization
Section IV. Signatures
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current VACCINE INFORMATION FACT SHEET FOR RECIPIENTS AND CAREGIVERSABOUT COMIRNATY (COVID-19 VACCINE, mRNA), THE PFIZER-BIONTECH COVID-19 VACCINE, AND THE PFIZER-BIONTECH COVID-19 VACCINE, BIVALENT (ORIGINAL AND OMICRON BA.4/BA.5) TO PREVENT CORONAVIRUS DISEASE 2019 (COVID-19) FOR USE IN INDIVIDUALS 12 YEARS OF AGE AND OLDER. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless West End Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this West End Pharamcy to administer the vaccine(s). I authorize West End Pharmacy to bill either my insurance or HRSA (if no insurance) for the administration fee of the vaccine. West End Pharmacy may utilize my information provided to look up my insurance eligibility information.I understand the vaccine will be provided to me at no charge. If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Pharmacist Use Only:
Vaccine Card: 1st Dose:
GRITS: 2nd Dose:
BIVALENT BOOSTER DOSE:
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