Finksburg Pharmacy COVID-19 Vaccination Consent Form

The following questions will help us determine if there is any reason you should vaccine(s) today. If you answer "YES" to any question, it does not necessarily mean you should not be vaccinated. It means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.

*Persons who have had a severe reaction to a vaccine or currently have an acute febrile illness should not receive a vaccine. I certify that all information provided on this form is correct. I consent to the staff to administer the vaccination(s) mentioned below. I understand that this vaccine has been authorized by the FDA under an Emergency Use Authorization and I have reviewed the fact sheet that has been provided to me concerning the specific manufacturer of the vaccine I am receiving today. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of receiving this vaccine and choose to assume this risk. I fully release and discharge the pharmacist and the pharmacy, its affiliations and their officers and employees from any illness, injury, loss, or damage that may result there from. I acknowledge that I have received a copy of the pharmacy's privacy policies according to HIPAA. I assign payment of authorized insurance benefits due to me to be paid to the pharmacy. I consent the release of medical information when necessary for billing, reimbursement, and medical protocol. I also allow for the pharmacy to report any vaccinations received to the appropriate state vaccine registry. I am aware that an immunization certified student pharmacist might be administering this vaccine. If obtaining my third mRNA primary series dose, I self-attest that I have been notified of the eligibility requirements and I meet one or more of the immunocompromised criteria. I agree to wait near the vaccination area for a minimum of 15 minutes or as otherwise instructed by the pharmacist so that I may receive treatment if I begin to feel unwell.

If receiving your Covid-19 vaccine, you may bring your CDC immunization record card for us to update.