Flu Clinic Consent Form 2021-2022

2021-2022 Influenza Vaccine Consent and Release Form

Online registration for flu clinics administered by Times Pharmacy
Section 1 of 4 - Vaccine Recipient Information

All 4 sections are required for each vaccine recipient. The information provided is protected under HIPAA privacy laws.
Available Appointments *
First Name *
Last Name *
MI
Last 4 digits of Social Security # *
Date of Birth *

Month Day Year
Gender *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Preferred Contact Phone Number *
Preferred Contact Email *

Confirmation Email Please enter email address twice to verify. We will send important information and required documents via email.
Name of Primary Care Provider (PCP)

First Name Last Name
PCP Phone Number

Section 2 of 4 - Insurance Information

If you have medical insurance coverage please provide the information below.
Medical Insurance Coverage *

Yes, I have coverage No, I do not have insurance coverage
Do you have Medicare Part B? *

Yes No
Medicare Part B ID # *
(example format: 1EG4-TE5-MK72)
Primary Insurance Plan Name *
Relationship to Cardholder *

Self Spouse Dependent
Cardholder Date of Birth *

Month Day Year
Cardholder ID # *
Cardholder First Name *
Cardholder Last Name *
If applicable on insurance card, please provide your RX BIN, RX GROUP, and RX PCN numbers.
RX BIN #
RX GROUP #
RX PCN #

Section 4 of 4 - Consent & Signature

Please read, initial, and sign for the acknowledgements below. This can only be completed by the vaccine recipient, parent of a minor, legal guardian, Power of Attorney (POA), or authorized signer.
Flu Vaccine Recipient Name
Locked in - please confirm the above is correct. If not then scroll down and press the "Back" button to make corrections.
Vaccine Recipient Date of Birth

Month Day Year
Locked in - please confirm the above is correct. If not then scroll down and press the "Back" button to make corrections.
Consent

I consent to receiving the flu vaccine from Times Pharmacy.

I understand that I am giving Times permission to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable Times to process my insurance claims with respect to the vaccination.

I understand that if my insurance does not pay for the services
rendered on this form, I am responsible for payment.

I, for myself, my heirs, executors and assigns hereby release Times and its
divisions and affiliates and their respective officers, directors, employees, agents and representatives from any and all claims arising out of or in connection with this vaccination.

I also acknowledge that I received a copy of the Vaccine Information Statement (VIS)for the vaccine stated below and that I understand the benefits and risks associated with the described vaccine. The VIS will be sent to the email address provided.
Acknowledgment *

I hereby certify that I agree to the statement above and the information I provided is correct, true, and complete to the best of my knowledge.
Relationship to Vaccine Recipient *

I am the Vaccine Recipient I am the Parent of a Minor / Legal Guardian / Power of Attorney / Authorized Signer
First Name *
Last Name *
Signature of Authorized Representative *
Date *

Month Day Year
Should be Empty:

2021-2022 Influenza Vaccine Consent and Release Form

Section 1 of 4 - Vaccine Recipient Information

Section 2 of 4 - Insurance Information

Section 3 of 4 - Pre-Vaccination Screening Questions

Section 4 of 4 - Consent & Signature