Section I. Appointment Scheduler
Section II. Personal Information
Section III. Questionnaire for Immunization
Section IV. Signatures
I understand the benefits and risks of the vaccine(s) being administered and have received a copy of the Vaccine Information Statement. 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, or in any way related to the administration of the vaccine(s) requested. I understand that the information contained on this form may be shared with the State Health Division and state immunization registries, and will remain confidential and will not be released without my consent. If eligible, I ask that payment of authorized Medicare benefits be made on my behalf to West End Pharmacy for the immunization administered to me by West End Pharmacy. I am authorizing any holder of medical or other information about myself to be released to centers for Medicare and Medicaid Services and its agents, including any information needed to determine any and all benefits for related services. 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:
Manufacturer: _____________________________ Dose: 0.5 or 0.7 ml
Inj. Site: L R Deltoid SQ IM
Date: ______/______/______ Grits:
VIS Date: _08_/_6_/_2021_ Faxed MD:
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