Please read carefully
I hereby give my consent to Peoples Rx to administer the vaccines I have elected to receive. With my signature, I certify that:
I am: (i) the patient and at least 18 years of age; (ii) the parent or guardian of the minor patient; (iii) the legal guardian of the patient; or (iv) a person authorized under the law of another state or a court order to consent for the child; OR
The persons identified under (ii), (iii), or (iv), in the preceding sentence are unavailable and I have authority to consent to the immunization of the child because I am a (i) grandparent; (ii) adult brother or sister; (iii) adult aunt or uncle; (iv) stepparent; or (v) another adult who has actual care, control, and possession of the child and has written authorization to consent for the child from a parent, managing conservator, guardian, or other person who, under the law of another state or a court order, may consent for the child; additionally, I certify that I do not have knowledge of any express refusals or withdrawn authorizations of consent and have not been told not to give consent for the child.
I understand that any Protected Health Information (PHI) I provide Peoples Rx will only be used or disclosed by Peoples in accordance with Peoples Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices. By signing below I acknowledge receipt of such HIPAA Notices of Privacy Practices and consent to the uses and disclosures of PHI described therein. I consent to Peoples Rx reporting my immunization information to the State Immunization Registry, ImmTrac2. I further understand that my immunization information may be accessed by healthcare providers, educators, public health representatives, state agencies, and certain insurance payers. I also authorize Peoples Rx to (1) release my medical information to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment or otherwise, (2) submit a claim to my insurer for the below requested items and services, and (3) request payment of authorized benefits be made on my behalf to Peoples Rx with respect to the below requested items and services.
I understand that Peoples Rx representatives are not physicians trained to diagnose and treat medical problems. I acknowledge that the administration of services does not constitute, and should not be interpreted as, medical advice or opinions substituting for the advice of a physician. I understand that the administration of services does not create a doctor-patient relationship between myself and Peoples Rx. I agree to consult a physician if I require medical advice or services at any time.
I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I have filled out and submitted the pre-vaccination checklist. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering health care provider. I understand that in the course of the administration, a Peoples Rx employee could be exposed to my blood. In such an event, I agree to comply with Peoples’ Post Exposure Plan.
On behalf of myself, my heirs and personal representatives, I further hereby WAIVE, RELEASE, and AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS (including for costs and attorney’s fees) Peoples Rx, it’s staff, and agents from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of vaccine(s) and related services, even should such damages or losses result from Peoples Rx’s negligence.
I have received, read, and/or had explained to me the Vaccine Information Statement (VIS) for the vaccine I have elected to receive.