Safeway Covid Vaccine Consent Form. (a) the patient and at least 18 years of age; Last name first name identification (e.g., health card number) gender:
Informed consent for immunization with inactivated vaccine. If you are being inoculated by cvs, we’ve included that form below. By my signature below, i consent to the administration of the vaccine(s) by a pharmacist or a supervised student pharmacist or technician, or other authorized person, where permitted by law or state/federal guidance, employed or contracted by albertsons companies or one of its affiliated pharmacies and to be contacted at the number provided
Table of Contents
That I Have The Legal Authority To Consent To This Immunization.
Individuals must complete a vaccine screening and consent form to confirm eligibility. Use fill to complete blank online others pdf forms for free. Last name first name identification (e.g., health card number) gender:
See The Accompanying Guide For Interpretation Of Responses Last Updated 12 Apr 2021 Vaccine Recipient Information Name:
5) i have been counseled about potential side effects after vaccination, when they Client parent legal decision maker other _____ (on behalf of client) b. For ages 18 years and older:
I Will Communicate The Information Provided To Me Today About My Vaccination To My Primary Care Provider, If I Have One.
4) i will immediately alert the pharmacist of any medical conditions which may adversely affect my personal health or effectiveness of the vaccine. (b) the parent or legal guardian of the patient and confirm that the patient is at least 16 years of age; Our drivers can also bring delivery orders into your home, if needed, but will ask you to keep a distance of six feet when doing so.
I Also Understand That I Should Wait In Store For A 15 Minute Observation Period After Receiving My Vaccine.
Inactivated flu vaccine quadrivalent (qiv) is a standard dose flu shot that protects against four strains of the flu virus. Print name date signature of patient or legal guardian And understand this informed consent for the vaccine listed below.
Once Completed You Can Sign Your Fillable Form Or Send For Signing.