Immunization Screening Questionnaire and Consent Form

I am aware of the potential risks and side effects of the vaccine as. described in the literature as well as the risk of the disease it prevents. I hereby waive any liability towards pharmacy and/or its administering employee of potential adverse effects associated with administration of the vaccine. I authorize the release of any medical or other information necessary to process the claim and I hereby assign all insurance, Medicare, Medicaid and other third-party payors' benefits for services rendered. I have been offered the HIPAA Privacy Policy.