I attest that I am eligible to receive vaccine based on state and county guidance. I have received a Notice of Privacy Practice for HIPAA. I have read, or have had read to me, the EUA information for the COVID vaccine I am receiving. I have been able to ask questions about the vaccine, and all my questions have been answered to my satisfaction. I consent to the administration of the vaccine requested. I understand that the vaccination information will be shared with the state immunization database. I agree to stay in the general area for 15-30 minutes after receiving my vaccination in case any immediate reactions occur. If I experience any side effects, I am responsible for following up with my physician at my expense. On behalf of myself, my heirs, and my personal representatives, I hereby release the pharmacy that is administering the vaccine(s); the subsidiaries and affiliates of the pharmacy; the respective directors, officers, employees, and agents of the pharmacy and its subsidiaries and affiliates; and the owner and/or operator of the clinic site and its directors, officers, employees, and agents from any and all liability that might arise from this vaccination.
Immunization Registry Consent
I authorize my health care provider and a public health agency to collect and enter my immunization records into the Department of Public Health and Human Services’ Immunization Information System (IIS). The IIS is a confidential, computer system that contains immunization records. I understand that information in the registry may be released to a public health agency as well as my health care providers to assist in my medical care and treatment. In addition, information may be released to schools in order to comply with immunization requirements. I understand that I can revoke this authorization and have my record removed at any time by contacting my local health department.