I authorize the release of any medical or other information with respect to this vaccine to my healthcare providers, Medicare, Medicaid or other third-party payer as needed and request payment of authorized benefits to be made on my behalf to AR-EX Pharmacy.
- I acknowledge that if my insurance does not cover the cost of administering the vaccine at the pharmacy, then payment must be made at the time of the administration of the vaccine.
- I acknowledge that my vaccination record may be shared with federal or state agencies for registry reporting.
- I acknowledge that the pharmacist recommends that vaccinated patient should remain in the waiting area, after the administration of the immunization, for 20 minutes.
- I have read, or have had read to me the Vaccination Information Sheet (VIS) regarding the vaccine(s). I have had the opportunity to ask questions that were answered to my satisfaction and understand the benefits and risks of the vaccines(s). I consent to, or give consent for, the administration of the vaccine(s). I fully release and discharge AR-EX Pharmacy, affiliate their officers, directors, and employees from any liability for illness, injury, loss, or damage which may result there from.