• Refill Pharmacy COVID-19 Vaccine Consent Form

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  • Medical History

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  • Consent to Immunize

  • I am aware of the potential risks and side effects of the vaccine as described in the literature as well as the risk of the disease it prevents. I hereby waive any liability towards pharmacy and/or its administering employee of potential adverse effects associated with administration of the vaccine. I authorize the release of any medical or other information necessary to process the claim and I hereby assign all insurance, Medicare, Medicaid and other third-party payors’ benefits for services rendered.

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  • We encourage you to download the V-Safe tool that uses text messaging and web surveys to provide personalized health check-ins after you receive a COVID-19 vaccine.  Through V-Safe, you can quickly tell CDC if you have any side effects after getting the vaccine.  V-Safe will also remind you to get your second COVID-19 vaccine.

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