I hereby give my consent to the health care provider of Rankos Pharmacy to administer vaccine(s). I understand the risks and benefits associated with the vaccine(s) being administered. I (or the party I am signing on behalf of) have received, read and/or had explained to me the CDC’s Vaccine Information Statement (VIS) on the vaccine(s) I (or the person I'm representing) have elected to receive. I have had the opportunity to ask all questions. My questions were answered to my satisfaction. As with any medical treatment, I realize I may experience an adverse reaction from the vaccine.
I have been advised to "Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088."
I understand the information may be shared with the Stated Health Division (SHD) and/or state immunization registries, and will remain confidential and will not be released except as permitted or required by law.
If the claim is denied, I understand that I will be responsible for payment.
Furthermore, I agree to remain near the vaccination location for approximately 15-20 minutes after administration for observation.
NOTE: (SIGNATURE OF PATIENT OR LEGAL GUARDIAN, IF PATIENT UNDER AGE 18) (FOR LEGAL GUARDIANS ONLY: PRINT NAME AND RELATIONSHIP).