• 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 also acknowledge that if this is being filled our for a booster dose that I have answered each question honestly.
• 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 years of age and older; and the emergency use of this product is only authorized forthe duration of the declaration that circumstances exist justifying the authorization 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 all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and havereceived, read and/or had explained to me the Emergency Use Authorization Fact Sheet 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 answered to 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 personal representatives, 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 registry and (b) Vashon Pharmacy will include my personal immunization information in the IIS 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 supplemental coverage payment for me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to Vashon Pharmacy or its agents with respect to the above requested items and services.
• I acknowledge receipt of the Notice of Privacy Rights.
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