Please review the statement below confirming your consent for vaccination and provide the information requested. I have read or have had explained to me, the Vaccine Information Statement regarding the vaccine(s) marked below. I understand the risks and benefits, and have been provided an opportunity to ask questions and they have been answered to my satisfaction. I wish to receive the vaccine(s) indicated below and hereby give consent for the pharmacist named below to administer said vaccine and communicate the administration of the vaccine to my primary care practitioner listed below.
For the services furnished to me by this provider, I authorize the release of medical information about me to the Centers for Medicare and Medicaid Services, South Carolina Medicaid, or any other carrier, payor or their agents to determine the benefits payable for related services. Furthermore, I authorized any covered entity to direct payment for such services to the above named provider.