IMMUNIZATIONS

Informed Consent, Financial Policy Agreement, and Acknowledgement of Notice of Privacy Practices 

 

I authorize The Vine Pediatrics and Lactation PLLC ("Practice") to administer immunizations for myself or my child on a date to be determined. 

I understand that I must provide The Vine Pediatrics and Lactation with a copy of my current health insurance information and current driver's license or passport prior to the appointment. I understand that a claim for the cost of the immunizations will be submitted to my health insurance company by VaxCare Corp.  If I do not have insurance that covers any or all of the vaccines, I am 100% responsible for the costs of the immunizations.  I understand that I am 100% financially responsible for any bills received by VaxCare or my health insurance company on my behalf or my child's behalf, and I will not hold the Practice, Dr. Sharifa Glass, or the Practice's staff liable for any monetary bills from VaxCare or my health insurance company.

I understand that I am a self-pay patient, and I will be responsible for paying for any services received.  These service fees will not be billed to my insurance company because The Vine Pediatrics and Lactation PLLC does not submit claims to insurance and does not bill insurance.  I acknowledge that the service fee is a monetary payment for one vaccine visit, and payment must be sent by Zelle (info@vinepediatrics.com) or Paypal (info@vinepediatrics.com). Payment is due prior to any services received. 

I understand that the The Vine Pediatrics and Lactation PLLC will report the immunizations administered during the appointment to ImmTraC (Texas Immunization Registry) if I elect to complete the ImmTrac consent form.

I understand that I am not a member of the The Vine Pediatrics and Lactation PLLC. I understand that the Practice does not offer medical advice beyond what is written on the Vaccine Information Sheets and does not provide medical treatment for non-members of the practice. I understand that I must follow-up with my own or my child's physician regarding medical advice, care, or treatment pertaining to the immunizations received. I will not hold the Practice, Dr. Sharifa Glass, or the Practice's staff liable for adverse reactions, progression of illness, or future illness.

I understand that immunization administration should not be used in place of CDC (Centers for Disease Control and Prevention) recommendations to social distance, wear a mask, and wash hands to decrease transmission of infections.

By signing below, I acknowledge that The Vine Pediatrics and Lactation has made the Notice of Privacy Practices available to me prior to any services being provided to me by the Practice. I consent to the use and disclosure of my medical information as set forth herein in the Notice. This includes authorization to enter personal and medical information into my electronic health records.

By signing below, I consent to receive immunizations administered by The Vine Pediatrics and Lactation PLLC on a date to be determined. 

 

BY SIGNING THIS FORM, I CERTIFY:

• That I have read or had this form read and/or had this form explained to me.
• I have the legal right to consent because I am the patient or I am the parent/guardian of the patient. All references to "patient", "me" and "my" in this document means: