Section 1: Information for Individual Receiving Vaccine
Section 2: Pre-Screening for Vaccine Eligibility
The following questions will help us determine which vaccines you may be given. Answering “yes” to any of these questions does not necessarily mean you should not be vaccinated.
* Please note those who have a moderate to severe illness with a fever should wait until they recover before getting vaccinated.
Section 3: Consent for Vaccination
I give my consent to Guardian Pharmacy, LLC, its affiliates, subsidiaries, and the licensed healthcare professional administering the vaccine, to administer the vaccine(s) I have requested above. I understand the risks and benefits associated with the vaccine(s) being administered and have received, read, and/or had explained to me the CDC’s Vaccine Information Statement (VIS) or the FDA’s Emergency Use Authorization (EUA) on the vaccine(s) I have elected to receive. I have had the opportunity to ask questions that were answered to my satisfaction. As with all medical treatments, I understand that there is no guarantee that I will not experience an adverse reaction from the vaccine. On behalf of the patient, the patient’s heirs and personal representatives, I hereby release and hold harmless Guardian Pharmacy, LLC, and its affiliates, subsidiaries, staff, agents, successors, divisions, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the requested and vaccine(s). I understand and agree that the information contained on this form may be shared with my medical provider(s), the State Health Division (SHD), my state’s health information exchange, state immunization registries, and/or other state or federal government agencies as required by law, for the purpose of public health reporting, or for the purpose of care coordination. I further authorize Guardian Pharmacy to (a) release my medical or other information to Medicare, Medicaid, or other third-party payers as necessary to effectuate care or payment; (b) submit a claim to my insurer for the requested items and services; and (c) request payment of authorized benefits be made on my behalf to Guardian Pharmacy, LLC, its affiliates, or subsidiaries, with respect to the requested vaccine(s). I agree to be fully financially responsible for any cost-sharing amounts, including copays, coinsurance, and deductibles, for the requested items and services, as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service or immediately upon receipt of an invoice for the service. I agree to remain near the vaccination location for approximately 15-30 minutes after administration for observation.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.