Section V. Consent
I certify that I am: (i) The patient and at least 18 years of age; (ii) The parent or legal guardian of the minor patient; or (iii) The legal guardian of the patient. Further, I hereby give my consent to the health care provider of Vaxon, LLC to administer the vaccine(S) I have requested above. I understand that it is not possible to predict all possible side effects or complications as associated with receiving the vaccine(s). I understand the risks and benefits associated with the above vaccine(s) and have read, and/or had explained to me the Vaccine Information Statements (VIS)/ Emergency Use Authorization sheet (EUA) on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering health care provider. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Vaxon, LLC its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of vaccine(s) listed above. I authorize Vaxon, LLC to release medical or other information to my health care professionals, Medicare, Medicaid or other third party payor necessary to effectuate care or payment and request that payment of authorized benefits be made on my behalf to Vaxon, LLC with respect to the vaccine(s) listed above. I also acknowledge that have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information. I consent that I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this Consent and Release.