I have read the Vaccine Information Sheet or fact sheet about the corresponding vaccine(s) I am receiving. I have had a chance to ask questions to my satisfaction. I understand the benefits and risks of the vaccine and request that the vaccine be given to me or to the person named above for whom I am authorized to make the request. I authorize the release of any medical information or other information necessary to process an insurance claim. I understand that if applicable, Specialty RX (Citywide RX LLC) will submit my claim to insurances they contract with. I certify that all Medicare information given to Specialty RX (Citywide RX LLC) Pharmacy is true. Specialty Rx (Citywide RX LLC) has made their “Notice of Privacy Practices” available to me. I authorized the release of any medical or other information with respect to this vaccine to my healthcare providers, Medicare, Medicaid, the HRSA COVID-19 program for the uninsured, or other third party payer as needed and request payment of authorized benefits to be made on my behalf to Specialty RX (Citywide RX LLC) Pharmacy. I acknowledge that my vaccination record may be shared with federal or state or city agencies for registry reporting. I agree to stay in the general area for at least fifteen (15) minutes after receiving my vaccination for any potential adverse reactions. I understand if I experience side effects that I should contact a doctor, pharmacy, call 911 if an emergency.
If signing on behalf of the patient, you affirm that you are authorized to provide the required consents on behalf of the patient