Note: If You Answered YES to any of the Questions Above, Please Consult with Your Prescriber or Pharmacist First
A). I hereby give my authorization to myPharmacy to administer my requested vaccine(s) chosen above. All of the benefits and risks of receiving this immunization has been explained and presented to me verbally, in print and via QR code on my phone/tablet. I also have been counseld to remain under pharmacist's direct observation between 15 to 30 minutes. I acknowledge that I have had a chance to have my questions answered to my contement. On behalf of myself, my heirs, & personal representatives, I fully release and exude myPharmacy, its personnell, owners, successor, divisions, affiliates, officers ,directors,contractors, and employees from any and all liabilities or claims whether known or unknown arising in any way related to the administration of the vaccine(s) administered to me or my loved ones that I have signed this consent form as guardian for.
B). I assign payment of authorized insurance benefits due to me to be paid to the pharmacy.
C). I consent to the release of medical information when necessary for billing, reimbursement & medical reasons between relevant parties associated with my health.
D). I consent to allowing myPharmacy report my IMZ records to VA-State Vaccine Registery System. and
E). I consent to receiving vaccinations by an Registered Pharmacy Intern when necessary. By initialing here, I consent to all the detailed elements stated in A, B, C, D, and E. I am ready to have myPharmacy immunize me and/or my dependents and/or my accompanying family.
