Tampa Urgent Care - Consent
Please read the following in it entirety, signature is required at the bottom.
Consent to Treatment
I certify that I am:
(a) the patient and at least 18 years of age;
(b) the legal guardian of the patient and confirm that the patient is at least 18
years of age; or
(c) legally authorized to consent for vaccination for the patient named above.
Further, I hereby give my consent to Tampa Urgent Care or its agents to administer the COVID-19 vaccine.
I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to
prevent Coronavirus Disease 2019 (COVID-19) for use in individuals either 18 years of age and older; and the
emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of
emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked
I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the
risks and benefits associated with the Moderna COVID19 vaccine and have reviewed, read the Emergency Use Authorization
Fact Sheet on the COVID-19 vaccine I have elected to receive.
I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes (or more in specific cases) after
administration for observation.
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the Tampa Urgent Care, and its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of Moderna COVID19 vaccine.
I acknowledge that:
(a) I understand the purposes/benefits of Florida SHOTS, Florida’s immunization registry and
(b) Tampa Urgent Care will submit my personal immunization information in Florida SHOTS and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies.
I further authorize Tampa Urgent Care, or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage
payment for me for COVID19 Vaccine administration. I assign and request payment of authorized benefits be made on my behalf to
Tampa Urgent Care or its agents with respect to COVID19 Vaccination and services.
I acknowledge receipt of the Tampa Urgent Care Notice of Privacy Practices.