Flu Shot Form – Fill Out and Use This PDF

SECTION C

I certify that I am: (i) the patient and at least 18 years of age; (ii) the parent or legal guardian of the minor patient; or (iii) the legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of Walgreens or Take Care Health ServicesSM, as applicable, to administer the vaccine(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering healthcare provider. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Walgreens or Take Care Health ServicesSM, as applicable, its staff, agents, successors, divisions, affiliates, subsidiaries, 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 vaccine(s) listed above. I acknowledge that: I understand the purposes/benefits of my state’s immunization registry (“State Registry”). I acknowledge that, depending upon my state law, I may prevent, by using a state-approved opt-out form (“Opt-Out Form”): (a) disclosure of my immunization information to the State Registry; or (b) the State Registry from sharing my immunization information with any of my other healthcare providers enrolled in the State Registry. Walgreens or Take Care Health ServicesSM, as applicable, will, if my state permits, provide me with an Opt-Out Form. Unless I provide Walgreens or Take Care Health ServicesSM, as applicable, with a signed Opt-Out Form, I elect to participate fully in, and consent to Walgreens or Take Care Health ServicesSM, as applicable, reporting my immunization information to the State Registry.

I authorize Walgreens or Take Care Health ServicesSM, as applicable, to (1) release my medical or other information, including my communicable disease (including HIV), mental health and drug/alcohol abuse information, to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment, (2) submit a claim to my insurer for the above requested items and services, and (3) request payment of authorized benefits be made on my behalf to Walgreens or Take Care Health ServicesSM, as applicable, with respect to the above requested items and services. I further agree to be fully financially responsible for any cosharing 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, if Walgreens or Take Care Health ServicesSM invoices me after the time of service, upon receipt of such invoice.

SECTION D (HEALTH CARE PROVIDERS ONLY) The following section is to be completed by the health care provider only.

Immunizer Name (print): ________________________________ Immunizer Signature: _____________________________ RPh/PharmD/RN/LPN/LVN/NP/PA (circle one)

If applicable, Intern Name (print): _________________________________ Administration Date: ______________________ Date VIS given to Patient: _________________