Influenza (Inactivated) Consent Form:
Administering Pharmacists Crystal Spaid, PharmD; Robbin Skipper, PharmD; Nicholas Gregg, PharmD; Ali Gregg, PharmD; Thomas Henline, PharmD; Carl Cathell Jr., RPh
I certify that I have received a copy of, read or had explained to me, and understand the CDC Vaccine Information Statement about the vaccination being administered. All of the information that I have provided above is true and complete to the best of my knowledge. information, and belief. Any questions that I had that are relevant to my decision to grant or withhold consent to the vaccine have been answered to my satisfaction. I agree to stay in the general area for up to twenty (20) minutes after receiving my vaccination for medical observation I authorized the release of any medical information or other information necessary to process an insurance claim if applicable. I also authorize a record of this immunization to be released to my physician and to the Maryland ImmuNet Immunization Registry. I understand and have fully considered the risks, possible side effects, and the potential benefits of the vaccine for the individual named below. My signature below indicates that I am granting to Gregg's Pharmacy and its authorized staff my permission and informed consent to administer the appropriate vaccine to the person named below. I understand that one or two doses may be necessary depending on the person's previous immunization history.