Section I. Personal Information
Section II. Questionnaire for Immunization
Section III. Signatures
I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information (injection VIS or mist VIS), a copy of which I was provided with this Consent and Release. I request the vaccine to be given to me or to the person named below, a minor for whom I represent that I am authorized to sign this Consent and Release.
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.