• COVID Vaccine Consent Form - Wells Hometown Drug

    COVID Vaccine Consent Form - Wells Hometown Drug

    * Please fill out the required details below
  • If you have remaining questions, please call us at 641-664-3100

  • Section I. Vaccine will be administered at Wells Hometown Drug

  • Section II. Personal Information

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  • Section III. Questionnaire for Immunization

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  • Section IV. Signature

    I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) available at wellshometowndrug.com. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.

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  • 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. You will receive a thank you page which means your submission was a success.

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