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Administration of J&J Janssen COVID-19 vaccine with other vaccines
History of a previous or current COVID-19 infection
History of unprotected exposure to a person who tested positive for COVID-19 in the last 14 days
If you have been treated with a monoclonal antibody or convalescent plasma
Consent for Service
I verify that I have been provided with and have read (or had read to me) (1) the Fact Sheet for Recipients and Caregivers for the Emergency Use Authorization (EUA) of the J&J Janssen COVID-19 vaccine ("Vaccine"), (2) this J&J Janssen COVID-19 Vaccination Consent and Release Form; and (3) any additional information provided to me concerning COVID- 19 vaccination. I acknowledge that I have had a chance to ask questions of a healthcare professional about the Vaccine. I understand that the Vaccine will be given and completed in one dose. I understand the known risks and the potential benefits of receiving the Vaccine, and I understand there may be risks to the Vaccine that are not known at this time. I understand that the FDA has authorized use of the Vaccine under an Emergency Use Authorization (EUA) and that there is currently not enough scientific evidence available for the FDA to fully approve this or any other COVID-19 vaccine. I nonetheless request and consent to the Vaccine being given to me.
Limitation of Liability
I understand that because this is not an FDA-approved vaccine but is being given under an FDA issued Emergency Use Authorization, Times Pharmacy Hawaii, its divisions and affiliates and their respective officers, directors, employees, agents and representatives are immune from civil liability under federal and state law for all claims for loss related to any known or unknown side effects and/or injuries, including but not limited to death, that I, or the person for whom I am authorized to make this request, may experience from this vaccine. This immunity means that if I file a lawsuit against Times Pharmacy Hawaii, the court must dismiss any such lawsuit, and the only exception to this immunity is for claims for willful misconduct.
Authorization to Release Information for Medical Treatment and/or Payment
I understand that I am giving Times Pharmacy Hawaii permission to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable Times Pharmacy Hawaii to process my insurance claims with respect to the vaccination.