Vaccinations at Avalina Pharmacy

I understand the benefits and the risks associated with the above vaccine. A copy of the vaccine information statement (VIS) and/or emergency use authorization (EUA) fact sheet has been provided to me. Furthermore, I have also had an opportunity to ask questions about the immunization. I believe the benefits outweight the risks and I voluntarily assume full responsibility for any reactions that may result from either my receipt of the immunization or the receipt of the immunization by the person named below for whom I am the legal guardian ('Ward'). I will alert pharmacist of any medical conditions which may adversely affect my personal health or effectiveness of the vaccine. I understand it is not possible to predict all possible side effects or complications associated with receiving the vaccine. My medical record may be shared with my physician or other healthcare provider and the medical record of my Ward may be shared with his/her physician or other healthcare provider. I am requesting that the immunization(s) be given to me or my Ward. I, for myself and on behalf of my Ward, and each of our respective heirs, executors, personal representatives and assigns, hereby release Avalina Pharmacy, and its affiliates, subsidiaries, divisions, staff, officers, directors, contractors, agents and employees (collectively "Released Parties"), from any and all claims arising out of, in connection with or in any way related to my receipt and the receipt by my injury, death or damage sufffered or sustained by any person at any time in connection with or as a result of this vaccine program or the administration of the vaccines described above. Avalina Pharmacy will use and disclose your personal and health information or the personal and health information of your Ward, to treat you or your Ward, to receive payment of the care we provide, and for other health care operations. Healthcare operations generally include those activities we perform to improve the quality of care. We have prepared a detailed NOTICE of PRIVACY PRACTICES to hlep you better understand our policies in regard to you and your Ward's personal health informaiton. I acknowledge that I have received a copy of the Notice of Privacy Practices. I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.

If patient is a minor (age 14 and younger in the state of Oregon), the parent or guardian must sign below to consent to the minor receiving vaccination.