ASSIGNMENT OF BENEFITS: I hereby assign to Ella Community Pharmacy any insurance or other third-party benefits available for the vaccine and administration fee of the influenza vaccine provided to me.
RELEASE OF INFORMATION: I agree to allow Ella Community Pharmacy to release information to the Indiana vaccine registry, CHIRP (Children and Hoosier Immunization Registry Program), to record that I have received this vaccine. This information will record of the manufacturer and administered dose(s) of the vaccine.
RECEIPT OF INFORMATION: I have had a copy of the Vaccine Information Statement (VIS) for the influenza vaccine made available to me. VIS Form Influenza Vaccine. I have had a chance to ask questions and believe I understand the benefits and risks of the vaccine made available to me.
VACCINATION CONSENT: I ask that the vaccine be administered to me or the person for whom I am authorized to make this request.