Section IV. Signatures
By signing this form I hereby give my consent to Tarrytown Pharmacy to administer the vaccine(s) I have requested. I certify that:
I am (i) the patient and at least 18 years of age; (ii) the parent or guardian of the minor patient; or (iii) the legal guardian of the patient; or (iv) a person authorized under the law of another state or a court order to consent for the child OR
The persons identified under (ii), (iii), or (iv) in the preceding sentence are unavailable and I have authority to consent to the immunization of the child because I am a (i) grandparent; (ii) adult brother or sister; (iii) adult aunt or uncle; (iv) stepparent; or (v) another adult who has actual care, control, and possession of the child and has written authorization to consent for the child from a parent, managing conservator, guardian, or other person who, under the law of another state or a court order, may consent for the child; additionally, I certify that I do not have knowledge of any express refusals or withdrawn authorizations of consent and have not been told not to give consent for the child.
I understand that any Protected Health Information (PHI) I provide to Tarrytown Pharmacy will only be used or disclosed by Tarrytown Pharmacy in accordance with Tarrytown Pharmacy's Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices. (Click HERE to view Notice of Privacy Practices) By signing below I acknowledge receipt of such HIPAA Notices of Privacy Practices and consent to the uses and disclosures of PHI described therein. While Tarrytown Pharmacy reserves the right to not do so, I consent to Tarrytown Pharmacy reporting my immunization information to the State Immunization Registry. Should Tarrytown Pharmacy elect to report my immunization history to the Texas central immunization registry, ImmTrac, I further understand that my immunization information may be accessed by other health care providers, educators, public health, representatives, state agencies, and certain insurance payers. I further authorize Tarrytown Pharmacy to (1) release my medical or other information to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment or otherwise, (2) submit a claim to my insurer for the below requested items and services, and (3) request payment of authorized benefits be made on my behalf to Tarrytown Pharmacy with respect to the below requested items and services.
NOT A SUBSTITUTE FOR A PHYSICIAN
I understand that Tarrytown Pharmacy representatives are not physicians trained to diagnose and treat medical problems. I acknowledge that the administration of Services does not constitute and should not be interpreted as medical advice or opinions substituting for the advice of a physician. I understand that the administration of Services does not create a doctor patient relationship between myself and Tarrytown Pharmacy. I agree to consult a physician if I require medical advice or services at any time.
RELEASE, IMDEMNITY AND DISCLAIMER
I understand that it is not possible to predict all possible effects or complications associated with receiving vaccines, including the novel COVID-19 vaccines. I understand the risks and benefits associated with novel vaccine(s) and elect to receive a COVID-19 vaccine. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. I additionally acknowledge that I have received a copy of the Tarrytown Pharmacy notice of privacy. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering health care provider. I understand that in the course of the requested vaccine administration, a Tarrytown Pharmacy representative could possibly be exposed to my blood or bodily fluids. In such event, I agree to review and execute the "Tarrytown Pharmacy Post-exposure Consent for Testing" form.
On behalf of myself, my heirs, and personal representatives, I further hereby WAIVE, RELEASE, and AGREE TO ENDEMNIFY, DEFEND, AND HOLD HARMLESS (including costs and attorney's fees) Tarrytown Pharmacy, its staff, agents, employees, and corporate affiliates from any and all liabilities or claims whether known or unknown arising out of, in connections with, or in any way related to the administration of COVID-19 vaccine(s) and related services, even should such damages or losses result from Tarrytown Pharmacy's negligence.
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) View Pfizer EUA by clicking here, a copy of which I was provided with this Consent and Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.
I have read and understood the acknowledgment letter provided above.
I declare that the information I have provided above is correct.
I am giving my full consent to get the COVID-19 vaccine of my own will.
I will show up
for my appointment.
If I miss my appointment for any reason I will
LOSE MY RESERVED COVID-19 VACCINE
and will be required to wait until new apointments are available.
I have been provided with the Vaccine Recipient Fact Sheet (
I have been provided with information about the CDC's V-safe After Vaccination Health Checker (