2674 N Halsted St. COVID-19 Vaccine Registration Form

Do you have any chronic health condition?

Please indicate all health issues that are considered within the risk group

Please list your current medication

Please list down your allergies

Please check the symptoms that apply

Have you been diagnosed with COVID-19?*

YesNo

If yes, please provide further details (date of diagnition, were you hospitalized or not, treatment, etc.)

I, the undersigned, hereby give consent for INSTAVAXX, LLC / (the Provider) to administer the vaccine(s) to the patient identified below. I understand that it is not possible to predict all possible side-effects or complications associated with receiving the vaccine(s).
I understand the known risks and benefits associated with the above vaccine(s) include; but are not limited to:
REFER TO CDC VACCINE INFORMATION SHEET.
The patient agrees to seek medical attention in the event he or she is concerned about experiencing any of these, or other, side-effects or symptoms. I understand that Provider will not provide medical care after the vaccine is administered. I acknowledge that I have been advised that the patient should remain near the vaccination location for
approximately 15-30 minutes of observation after administration of the vaccine(s), depending on prior allergies or medical condition(s). I acknowledge the purposes/benefits of my state’s vaccination registry ("State Registry") and health information exchange ("State HIE"). I understand that Provider may disclose my vaccination information to
the State Registry, State HIE, or to any state or federal governmental agencies or authorities ("Government Agencies"), such as state, county, or local Departments of Health or the federal Department of Health and Human Services, the Centers for Disease Control and Prevention, or their respective designees as may be required by law, for purposes of public health reporting, or to my healthcare providers enrolled in the State Registry and/or State HIE for purposes of care coordination. I understand that I may revoke consent to disclose my vaccine status by delivering a written notice to Provider. I further understand that even if I do not consent, or if I revoke my consent, applicable state or federal laws may still permit or require certain disclosures of my vaccination information. BY SIGNING BELOW:
I CONSENT TO RECEIVE THE VACCINE(S) DESCRIBED ABOVE, THE RISKS AND BENEFITS OF WHICH HAVE BEEN EXPLAINED TO ME. I HAD AN OPPORTUNITY TO FULLY INQUIRE ABOUT THE RISKS AND BENEFITS, I WAS GIVEN SUFFICIENT TIME TO REVIEW THIS INFORMED CONSENT, AND I WAS AFFORDED AN OPPORTUNITY TO ASK QUESTIONS, WHICH WERE ANSWERED TO MY SATISFACTION. ON BEHALF OF THE PATIENT, THE PATIENT HEIRS AND PERSONAL REPRESENTATIVES, I HEREBY RELEASE AND HOLD HARMLESS PROVIDER, ITS SHAREHOLDERS,
MEMBERS, MANAGERS, 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 THE VACCINE(S)
LISTED ABOVE.
I CONFIRM I AM: (A) THE PATIENT AND AT LEAST 18 YEARS OF AGE;
(B) THE LEGAL GUARDIAN OF THE PATIENT; OR

(C) A PERSON LEGALLY AUTHORIZED TO CONSENT ON BEHALF OF THE PATIENT
WHERE THE PATIENT IS NOT OTHERWISE COMPETENT OR UNABLE TO CONSENT FOR HIMSELF OR HERSELF.

Signature

COVID-19 Vaccine Registration

Health and Medical History