I understand that the pharmacy advises me to remain within the pharmacy at least 20 minutes after the injections for observation. I will notify the pharmacy of any adverse events associated with immunization. Permission is herby granted to Keeseville Pharmacy to release information to my primary care provider, identified above, regarding any vaccinations received today. I agree to be vaccinated today with the Influenza Vaccine.
Our Pharmacy and the New York State Department of Health want to inform you about the Statewide Immunization Information System(IIS) By law, any immunizations given to patients under the age of 19 must be reported into a secure web-based IIS and this electronicsystem is Called the New York State Immunization Information System (NYSIIS).For patients aged 19 and older, immunizations may be reported to NYSIIS with patient consent. Inclusion of adults will significantly contribute to a fully-developed, population-based database of accurate immunization records, and complete date is essential to developing statewide immunization programs intended to reduce the burden of vaccine preventable disease.
By signing below, I agree to the reporting of my vaccine administration to NYSIIS