Dexter | Vaccine Consent Form

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

Clear
Date

MonthDayYear
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.
When you click "Submit" you will be redirected to a calendar to schedule your apppointment time. If you do not complete this step, we cannot guarantee that we will have a vaccine available for you.
Should be Empty:

VACCINE INFORMED CONSENT FORM

PATIENT INFORMATION

SCREENING QUESTIONS