Consent, Waiver, Vaccine Information Statement
Mena LLC, DBA The Medicine Shoppe 2057
VACCINE INFORMATION STATEMENT
All VIS for vaccines The Medicine Shoppe gives can found at the following link on CDC website.
CONSENT FOR SERVICES:
I have received and read (or had read to me) the Vaccine Information Statement(s), Vaccine Information Fact Sheet(s) and/or Patient Fact Sheet(s) regarding the vaccine(s). I understand the benefits and risks of vaccination. I voluntarily assume full responsibility for any reactions or consequences that may result. People receiving mRNA COVID-19 vaccines (Pfizer-BioNTech), especially males aged 5-29 years, should be aware of the rare possibility of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining outside the heart) following receipt of mRNA COVID-19 vaccines and the need to seek care if symptoms of myocarditis or pericarditis (such as chest pain, shortness of breath, or palpitations) develop after vaccination.
I voluntarily assume full responsibility for any reactions or consequences that may result. I understand I should remain in the vaccine administration area for 15 minutes, or longer if directed, after vaccination to be monitored for potential adverse reactions. If a reaction occurs, I can submit a VAERS adverse event report through this site.
I request that the vaccine be given to me (or to the person named, for whom I am authorized to make this request). In the event of side effects, I understand I should call my doctor or 911. I certify that the information provided regarding eligibility for the vaccine is accurate.
If I checked YES to any of the prior “Medical History” questions and its the vaccine recipient’s first dose of a vaccine, I will confirm with my doctor’s office that it is okay for me to receive the vaccine prior to my appointment. I have received/read (or had read to me) the Vaccine Information Statement(s) below, Vaccine Information Fact Sheet(s) and/or Patient Fact Sheet(s) regarding the vaccine(s). I understand the benefits/risks of vaccination. I understand I should remain in the vaccine administration area for 15 minutes, or longer if directed, after vaccination to be monitored for potential adverse reactions. I certify the information provided regarding eligibility for the vaccine is accurate and request the vaccine be given to me or the person previously named for whom I am authorized to make this request. If I am signing on behalf of another individual (including a minor), I attest I have the authority to do so. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless The Medicine Shoppe, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s).I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless The Medicine Shoppe, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I authorize The Medicine Shoppe to release information to Medicare, Medicaid or any other third party payer as needed and to request payment of authorized benefits to be made on my behalf, I certify the information provided about my Medicare, Medicaid or other coverage is correct. Please be aware that by entering the area of the pharmacy or clinic, you consent to your voice, name, and/or likeliness being used, without compensation, in photography or film and media, and you release The Medicine Shoppe, its successors, assigns, and licensees from any liability. I will inform a member of the staff if I wish not to be included in any photos, film, or media.
AUTHORIZATION TO REQUEST PAYMENT:
I authorize MENA LLC DBA The Medicine Shoppe to release medical information to Medicare, Medicaid or any other third party payer as needed and to request payment of authorized benefits to be made on my behalf to The Medicine Shoppe. I certify that the information provided about my Medicare, Medicaid or other coverage is correct.
DISCLOSURE OF RECORD:
I understand that The Medicine Shoppe may be required to or may voluntarily disclose my health information with respect to this vaccine to my healthcare providers, my insurance plan or other third party payer, health systems and hospitals, and/or state or federal registries.