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For Elders & Families
Resident Family Influenza Vaccine Consent Form
Nazareth Home Campus
*
Clifton
Highlands
Resident Name
*
First
Last
Resident Date of Birth
*
MM slash DD slash YYYY
(mm/dd/yyyy)
Room Number
*
Do you wish to receive influenza vaccine according to the recommended schedule. (This vaccine is offered annually.)
*
Yes
No
Reasons for declining.
Already Received
Select
Date Received
MM slash DD slash YYYY
Allergic
Select
Comment
Other
Select
Comment
CONSENT FOR SERVICES: I have been provided with the Vaccine Information Sheet(s) corresponding to the vaccine(s) that I am receiving. I have read or have had explained to me the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccination and I voluntarily assume full responsibility for any reactions that may result. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request.
AUTHORIZATION TO REQUEST PAYMENT: I do hereby authorize CVS Pharmacy® (“CVS®”) to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid is correct. I authorize the release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.
DISCLOSURE OF RECORDS: I understand that CVS® may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at CVS (if applicable), my Primary Care Physician (if I have one), my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or other health care operations (such as administration or quality assurance). I also understand that CVS will use and disclose my health information as set forth in the CVS Notice of Privacy Practices (copy is available in-store, online or by requesting a paper copy from the pharmacy).
I have read the CDC informational handout, have been given the opportunity to ask questions, and understand the flu information provided. This facility and its employees will not be held responsible for any adverse reactions to this vaccine now or in the following years. Local site reactions are expected in 5-10% of vaccine recipients. Less than 1% of vaccines have reported slight elevations of body temperature but severe allergic reactions have not been documented.
CDC Flu Shot Information Sheet
Signature
*
Date
*
MM slash DD slash YYYY
Responsible Party
*
First
Last
X
