By signing, I consent to the following:
- I understand the benefits and risks of the COVID-19 vaccine as described in the Vaccine Information Sheet (VIS), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
- I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I hereby give my consent to the pharmacist of Eastridge-Phelps Pharmacy/EP Medical, to administer the vaccine(s) I have requested. I understand the risks and benefits associated with the vaccine(s) being administered and have received, read and/or had explained to me the CDC's Vaccine Information Statement (VIS) on the vaccine(s) I have elected to receive. I have had the opportunity to ask questions that were answered to my satisfaction. As with all medical treatment, there is no guarantee that I will not experience an adverse reaction from the vaccine or medication. I fully release and hold harmless Eastridge-Phelps Pharmacy/EP Medical, its pharmacists and employees from any and all liabilities or claims arising out of, in connection with, or in any way related to the administration of the vaccine(s) given. I understand that the information contained on this form may be shared with the Stated Health Division (SHD) and/or state immunization registries and will remain confidential and will not be released except as permitted or required by law. If eligible, I authorize Eastridge-Phelps Pharmacy/EP Medical to submit a claim for reimbursement on my behalf to Medicare or any other contracted third-party payer. If the claim is denied, I understand that I will be responsible for payment. I acknowledge that I have received a copy of the Eastridge-Phelps Pharmacy Notice of Privacy Practices. Furthermore, I agree to remain near the vaccination location for approximately 15-20 minutes after administration for observation by the administering pharmacist.