COVID Vaccine Consent

By signing below, I certify the following:

Consent for services: I have been provided with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) that I am receiving. I have read the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understand that I am receiving a vaccine that has been approved through the Emergency Use Authorization process of the FDA. I understand the benefits and risks of vaccination and I voluntarily assume full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored for any potential adverse reactions. I understand if I experience side effects that I should do the following: call pharmacy, contact doctor, call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request.

Authorization to request payment: I do hereby authorize Kelley-Ross Pharmacy (KR) to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or the HSRA COVID-19 Program for uninsured patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.

Disclosure of records: I understand that KR may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at KR (if applicable), my primary care physician (if I have one), my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or other healthcare operations (such as administration or quality assurance). I also understand that KR will use and disclose my health information as set forth in the KR notice of privacy practices (copy is available in store, online, or by requesting a paper copy from the pharmacy). If I am receiving a vaccine through clinic, I understand that my name, vaccine appointment date and time will be provided to the clinic coordinator. I have answered the above questions knowing they represent risks to receiving vaccines. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccines cited and ask that the vaccine(s) below to be given to me or to the person named above (for whom I am authorized to make this request.) I understand that it is recommended that I stay on the premises for 15 minutes after the vaccine is given in case of complications.