Immunization Consent Form - Delta Pharmacy (Page 2 of 2) in pdf

Consent for Vaccine Administration

1. I understand Delta Pharmacy is providing vaccine(s) to me in a safe and convenient setting.

2. This does not take the place of an ongoing relationship with my primary care provider.

3. The Delta Pharmacy will provide your primary care provider with records of the vaccine(s)

administered here so that your medical records may be complete, but be sure to take your personal

records with you to your next appointment.

ACKNOWLEDGEMENTS

I acknowledge and attest to the following:

 I have read and understand the Vaccine Information Statement including information on

adverse reactions that I may experience as a result of receiving the vaccine. I have had the

opportunity to ask the pharmacist questions concerning the vaccine and the Vaccine

Information Statement, and my questions have been answered to my satisfaction.

 I have received the Notice of Privacy Practices disclosing my rights to my medical

information.

 I have answered the above questions truthfully. By answering yes, the pharmacist may

choose to not vaccinate, or I may be at a greater risk for adverse reactions.

 I understand it is not possible to predict all possible side effects or complications associated

with receiving vaccine(s).

 If I have insurance coverage, I am responsible for providing the correct information and

take responsibility for all copayments and deductibles.

 I voluntarily agree and consent to be immunized by the pharmacist.

 Delta Pharmacy shall not, at any time, or to any extent allowable by applicable law, be

liable, responsible, or in any way be accountable for any loss, injury, death, or damage

suffered or sustained by me or any other person at any time in connection with, or as a

result of, the administration of the Vaccine to me by the pharmacist.

 I have been advised to remain near the vaccination location for approximately 20 minutes

after administration for observation.

Vaccine Recipient’s Name: _________________________________ Date of Birth _________________

Vaccine Recipient Legal Representative’s Name if under 18: ___________________________________

Vaccine Recipient or Vaccine Recipient’s Legal Representative:

Signature:_______________________________________________ DATE: _______________________

Revised 12/2/2015

Immunization Consent Form - Delta Pharmacy Page 2