I have received the Vaccination Information Sheet (VIS) electroincally, paper availabe upon request, regarding the vaccine(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). I consent to, or give consent for, the administration of the vaccine(s) marked above and the notification of my primary care physician. I fully relsease and discharge Hoagland Pharmacy, its affiliates, directors, and employees from any liability for illness, injury, loss, or damage which may result there from.
For Medicare recipients, I hereby authorize the pharmacy to bill Medicare Part B on my behalf. I request that payment of authorized Medicare benefits be made to the pharmacy for teh marked vaccine(s) and administration as furnished to me by the pharmacy. I authroize any holder of medical information about me to release to the Center for Medicare and Medicaid Services (CMS) and its agents any information needed to determine these benefits payable for related services.