I authorize the release of any medical or other information with respect to this vaccine to my health care providers, Medicare, Medicaid or other third party payer as needed and request payment of authorized benefits to be made on my behalf to Rockville Centre Pharmacy.
I acknowledge that if my insurance does not cover the cost of administering the vaccine at the pharmacy, then payment must be made at the time of the administration of the vaccine.
I acknowledge receipt of the pharmacy’s Notice of Privacy Practices for Protected Health Information.
I acknowledge that the administration of an immunization or vaccine does not substitute for an annual check-up with the patient’s primary care physician.
I acknowledge that my vaccination record may be shared with federal or state agencies for registry reporting.
I acknowledge that the pharmacist recommends that vaccinated patients should remain in the waiting area, after the administration of the immunization, for 15 minutes.
I have read or have had read to me the Vaccination Information Sheet (VIS) regarding the vaccine(s). I have had the opportunity to ask questions that were answered to my satisfaction and understand the benefits and risks of the vaccine(s). I consent to, or give consent for, the administration of the vaccine(s).
I fully release and discharge Rockville Centre Pharmacy, its affiliates, their officers, directors, and employees from any liability for illness, injury, loss, or damage which may result therefrom.