Vaccine Consent Form (with COVID)

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INSURANCE INFORMATION*

I hereby authorize the pharmacy to bill my Insurance on my behalf for the immunizations and receive payment.I do not authorize the pharmacy to bill my insurance.

Insurer

Member #

Rx Group

BIN #

PCN #

Last 4 Digits of Social Security Number

Moderna COVID-19 12+ VIS | Moderna COVID-19

Pfizer COVID-19 12+ VIS | Pfizer COVID-19

Flu Injection VIS | Flu Mist VIS

Pneumonia VIS | Shingles VIS | RSV VIS

Other Vaccine Information Statements can be found by clicking here

ACKNOWLEDGEMENTS

I attest that the answers provided here are accurate to the best of my knowledge.I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent & Release. 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 & Release.I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy & of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.Consent forRegistration and Release of Immunization Records to Authorized Persons /Entities I understand that,by granting the consent below, I am authorizing release of my immunizationinformation to DSHS and I further understand that DSHS will include thisinformation in the Texas Immunization Registry. Once in the Texas ImmunizationRegistry, my immunization information may by law be accessed by: a Texasphysician, or other health-care provider legally authorized to administervaccines, for treatment of the individual as a patient; a Texas school in whichthe individual is enrolled; a Texas public health district or local healthdepartment, for public health purposes within their areas of jurisdiction; astate agency having legal custody of the individual; a payor, currentlyauthorized by the Texas Department of Insurance to operate in Texas forimmunization records relating to the specific individual covered under thepayor’s policy. I understand that I may withdraw this consent at any time bysubmitting a completed Withdrawal of Consent Form in writing to the TexasDepartment of State Health Services, Texas Immunization Registry.

Signature of Patient to Receive Vaccine (or Signature of Power of Attorney or Legal Guardian)

Date

Parent/Guardian Name

Relationship to patient

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

VACCINE INFORMED CONSENT FORM

PATIENT INFORMATION

SCREENING QUESTIONS