*This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing
I understand the benefits and risks of the COVID-19 vaccine as described in the Fact Sheet for recipients/caregivers and the HIPAA notice of privacy practice, a copy of which will be provided in the confirmation email after this Consent and Release. I have had a chance to ask questions that were answered to my satisfaction. For insurance recipients: I authorize the release of any medical information necessary to process this claim. I request payment of all insurance/government benefits to Pharmedico Pharmacy. I request the vaccine to be given to me or to the person named above, a minor for whom I represent and for whom I am authorized to sign this Consent and Release.
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Signature of Person to Receive Vaccine (or Parent/Guardian, if Recipient is a Minor ) *
*By clicking the “Submit” button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.