Patient Acknowledgment and Consent for Vaccination
I hereby acknowledge and agree to the following:
- Voluntary Request and Eligibility
I am at least 18 years of age and have voluntarily requested to receive the vaccination(s) indicated above. I understand that I may refuse vaccination at any time prior to administration.
- Information and Understanding
I have received, read, and had the opportunity to ask questions about the Vaccine Information Statements (VIS) for the vaccines I am receiving today. I understand the nature, purpose, benefits, and potential risks of the vaccination(s).
- Accuracy of Health Information
I affirm that I have answered all health screening questions accurately and to the best of my knowledge. I understand that providing incomplete or inaccurate information may increase the risk of an adverse reaction.
- Observation Period
I have been advised to remain in the vaccination area for at least 15 minutes after receiving the vaccine(s) to monitor for any immediate reactions and to notify the vaccinator of any symptoms such as dizziness, weakness, rash, or shortness of breath.
- Authorization for Use and Disclosure of Information
I authorize the release of my vaccination and relevant medical information to healthcare providers, public health authorities, immunization registries, and third parties (such as my primary care provider, insurer, or pharmacy benefit manager) as required for care coordination, billing, and public health reporting purposes. I understand that such disclosures will comply with HIPAA privacy requirements.
- Assumption of Responsibility
I understand that although adverse reactions are rare, they can occur, and the vaccination provider and administering pharmacy are not responsible for adverse events beyond those required to be reported by law.
- Acknowledgment of Understanding
By signing below, I confirm that I have read or had these terms read to me, that I fully understand their contents, and that I consent to receive the vaccine(s) indicated above.