For Covid-19 Vaccine:
I request the vaccine to be given to me or to the person named above, a minor for whom I represent and I am authorized to sign this consent form. I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided with this consent form (online or in print). I have had a chance to ask questions that were answered to my satisfaction. I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur. I understand that I will be receiving the vaccination at no cost to me. If insured, I authorize the pharmacy to bill my insurance on my behalf for the the immunization – understanding that I will not incur any costs. If uninsured, I attest that I do not have any insurance, including, but not limited to Medicare, Medicaid, or any other private or government-funded benefit plan. If uninsured, I authorize the pharmacy to use my social security number or driver’s license number to bill the United States Health Resources & Services Administration’s COVID-19 Program, understanding that I will not incur any costs. I understand that at this time, some COVID-19 vaccines require 2 doses given 21-28 days apart dependent on the manufacturer. If this is my first dose of the COVID-19 vaccine and a second dose is required (Pfizer and Moderna only), I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the Fact Sheet to complete the series.
For all other Vaccines:
By signing this form, I agree to be vaccinated today by El Dorado TrueCare Pharmacy. I have received and understand information about the vaccines designated above. I have had my questions answered to my satisfaction. I oauthorize the payment of medical benefits to the provider performing the service. If I have a copayment or the vaccine is not covered on my insurance, I will remit payment to El Dorado TrueCare Pharmacy.