VACCINE ADMINISTRATION RECORD (VAR) & INFORMED CONSENT

PATIENT INFORMATION:
LAST NAME_______________________________ FIRST NAME ___________________ MIDDLE INITIAL ____
DATE OF BIRTH_________________ ALLERGIES__________________________________________________
ADDRESS __________________________________________________________________________________
HOME PHONE __________________ CELL ___________________ EMAIL ______________________________
MOTHER’S MAIDEN NAME ____________________________________________________________________
PRIMARY CARE PHYSICIAN _______________________ PHONE # _____________ FAX # _________________

INFORMED CONSENT:

I certify that I am: (a) the patient and at least 18 years of age; (b) the parent or legal guardian of the minor patient; or (c) the legal guardian of the patient. Further, I
hereby give my consent to the healthcare provider to administer the vaccine(s) I have requested. 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
the applicable Provider, 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: (a) I
understand the purposes/benefits of my state’s immunization registry (“State Registry”) and my state’s health information exchange (“State HIE”); and (b) the applicable
Provider may disclose my immunization information to the State Registry, to the State HIE, or through the State HIE, to the State Registry, for purposes of public health
reporting or to my health care providers enrolled in the State Registry and/or State HIE for purposes of care coordination. I acknowledge that, depending upon my state’s
law, I may prevent, by using a state-approved opt-out form or, as permitted by my state law, an opt-out form (“Opt-Out Form”) furnished by the applicable Provider: (a)
the disclosure of my immunization information by the applicable Provider to the State HIE and/or State Registry; or (b) the State HIE and/or State Registry from sharing
my immunization information with any of my other healthcare providers enrolled in the State Registry and/or State HIE. The applicable Provider will, if my state
permits, provide me with an Opt-Out Form. I understand that, depending on my state’s law, I may need to specifically consent, and to the extent required by my state’s
law, by signing below, I hereby do consent to the applicable Provider reporting my immunization information to the State HIE, or through the State HIE and/or State
Registry to the entities and for the purposes described in this Informed Consent form. Unless I provide the applicable Provider with a signed Opt-Out Form, I understand
that my consent will remain in effect until I withdraw my permission and that I may withdraw my consent by providing a completed Opt-Out Form to the applicable
Provider and/or my State HIE, as applicable. I understand that even if I do not consent or if I withdraw my consent, my state’s laws may permit certain disclosures of
my immunization information to or through the State HIE as required or permitted by law. I also authorize the applicable Provider to disclose my, or my child’s (or
unemancipated minor for whom I am authorized to act as guardian or in loco parentis) proof of immunization to the school where I am, or my child (or unemancipated
minor for whom I am authorized to act as guardian or in loco parentis) is, a student or prospective student. I further authorize the applicable Provider to (a) release my
medical or other information, including my communicable disease (including HIV), mental health and drug/alcohol abuse information, to, or through, the State HIE to
my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment, (b) submit a claim to my insurer for the above
requested items and services, and (c) request payment of authorized benefits be made on my behalf to the applicable Provider with respect to the above requested items
and services. I further 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, the applicable Provider invoices me after the time of service, upon receipt of such invoice.

PATIENT SIGNATURE: _______________________________________________ (PARENT OR GUARDIAN IF MINOR) DATE:__________________

VAR: MAKE ANY ADDITIONAL NOTES ON BACK OF FORM, SCAN FORM INTO PT’S MEDICAL RECORD
NDC or SITE OF VIS
VACCINE MFG LOT EXP DOSE/ROUTE
STICKER ADMIN DATE

IMMUNIZER NAME/TITLE: _________________________________ SIGNATURE _________________________