I have read, or have had explained to me, the information regarding the vaccine(s)/immunizations(s) marked above. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and authorize the administration of the vaccine to me or the persons named below for who I am authorized to make the decision.
I, for myself, my heirs, and executors release MediCenter Pharmacy as the Medicare provider, any retail or external site, physician, and employees, from any and all claims arising out of or in a way related to my receipt of this or these immunizations(s MediCenter Pharmacy and the aforementioned related parted shall not at any time or any extent be liable or responsible for any loss, injury, death or damage to be suffered or sustained at any time as a result of this vaccination program. I consent the release of this information to my Primary Care Physician as listed above to document receipt of vaccination. I agree to wait in the vaccination location for approximately 5 minutes for observation after the vaccination(s).
Acknowledgement of Notice of Privacy Practices: I have received a notice of privacy practices. I understand that this document provides an explanation of ways in which my health information may be used or disclosed by MediCenter Pharmacy and of my rights with respect to health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.