If you are a minor under the age of 18, this form has to be completed and signed by your parent or guardian.
Please note that minors are not allowed to drive themselves through the vaccination drive-through clinic. They can be passengers or come to the walk-up clinic in the tents next to the pharmacy.
If you are the parent or guardian of the minor who needs an appointment, please click HERE to begin filling out the form.
Due to your history of anaphylaxis, Vashon Pharmacy, the MRC and our team of doctors would advise that you receive this vaccine in a clinical setting. Should you experience an anaphylatic reaction, we advise you be at a location that can administer more immediate care for you should this problem arise. Thank you for your interest in our vaccine site. You may submit this form now or simply close the window to exit.
Due to recent CDC recommendations and studies based on outcomes reviewed in patients with a history of COVID-19, it is recommended that you delay vaccination. Once 90 days have passed since your COVID-19 infection, we look forward to proceeding with the vaccination process. If you have questions regarding this particular situation we are happy to discuss them with you.
• I certify that I am: (a) the patient and atleast 18 years of age; (b) the legal guardian of the patient and confirm thatthe patient is at least 18 years of age; or (c) authorized to consent forvaccination for the patient named above. Further, I hereby give my consent to VashonPharmacy or its agents to administer the COVID-19 vaccine.
• I understand that this product has not been approved orlicensed by FDA, but has been authorized for emergency use by FDA, under an EUAto prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 18 yearsof age and older; and the emergency use of this product is only authorized forthe duration of the declaration that circumstances exist justifying theauthorization of emergency use of the medical product under Section 564(b)(1)of the FD&C Act unless the declaration is terminated or authorization revokedsooner.
• I understand that it is not possible to predict allpossible side effects or complications associated with receiving vaccine(s). Iunderstand the risks and benefits associated with the above vaccine and havereceived, read and/or had explained to me the Emergency Use Authorization FactSheet on the COVID-19 vaccine I have elected to receive. I also acknowledgethat I have had a chance to ask questions and that such questions were answeredto my satisfaction.
• I acknowledge that I have been advised to remain near thevaccination location for approximately 15 minutes (or more in specific cases)after administration for observation. If I experience a severe reaction, I willcall 9-1-1 or go to the nearest hospital.
• On behalf of myself, my heirs and personalrepresentatives, I hereby release and hold harmless the Vashon Pharmacy, the WashingtonDepartment of Health (DOH), and their staff, agents, successors, divisions,affiliates, subsidiaries, officers, directors, contractors and employees fromany and all liabilities or claims whether known or unknown arising out of, inconnection with, or in any way related to the administration of the vaccinelisted above.
• I acknowledge that:(a) I understand the purposes/benefits of Washington’s immunization registryand (b) Vashon Pharmacy will include my personal immunization information in theIIS registry and my personal immunization information will be shared with theCenters for Disease Control (CDC) or other federal agencies.
• I further authorize Vashon Pharmacy or its agents tosubmit a claim to my insurance provider or Medicare Part B without supplementalcoverage payment for me for the above requested items and services. I assignand request payment of authorized benefits be made on my behalf to Vashon Pharmacyor its agents with respect to the above requested items and services.
• I acknowledge receipt of the Notice of Privacy Rights.
By clicking signing below I accept these terms and conditions.