Consent and waiver: I consent to the staff to administer the medication(s) mentioned below. I have reviewed the vaccine information sheet(s) and understand the benefits and risks of receiving this medication and choose to assume this risk. I fully release and discharge the standing order physician (list physician) and the pharmacy, its affiliations and their officers, and employees from any illness, injury, loss, or damage that may result there from. I acknowledge that I have received a copy of the pharmacy’s privacy policies according to HIPAA. I assign payment of authorized insurance benefits due to me to be paid to the pharmacy and will pay any copay or deductible that result. I consent the release of medical information when necessary for billing, reimbursement, and medical protocol. I also allow for the pharmacy to report any medications received to the appropriate state vaccine registry. I am aware that an immunization certified student pharmacist might be administering this medication. I agree to wait near the vaccination area for approximately 20 minutes to receive treatment in case of adverse reaction. (Please sign on next screen)
