By initialing below, the patient or the guardian of the patient understands that:
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By initialing below, I attest that I understand and agree to the following regarding fees for services provided by the Travel Clinic:
By initialing below, I attest that I understand the risks and benefits of the immunizations that were recommended to me by the Travel Clinic. I understand that vaccination/immunizations from illness or disease is voluntary. For any reason, if I choose not to accep the recommended immunizations, I do not hold the Travel Clinic or any of its personnel accountable for any risks incurred for being unvaccinated and unprotected from potential illness or disease.
I understand the interactions, allergies, warnings, precautions and potential adverse reactions regarding the medications and immunizations that I reeived at the Travel Clinic. I have read the information on the vaccine information statement sheet (VIS from the CDC) and understand the information. I voluntarily consent to receive the mediations and/or immunizations.
By signing below, I hereby consent to evaluation, testing and treatment for me or the named patient as directed by the physician or his or her designee at the Travel Clinic. By signing below, I certify I have read and understand and agree to the consent on this page including the HIPAA PRIVACY CONSENT, FINANCIAL POLICY, REFUSAL OF RECOMMENDED IMMUNIZATIONS, AND CONSENT TO TREAT.