Immunizations

I voluntarily request and consent that a pharmacist employed by Wellspring Pharmacy administer to me the vaccine(s) (“Vaccine”) selected above. I acknowledge that Wellspring Pharmacy has provided me with a copy of the Vaccine Information Statement, which includes details about potential adverse reactions I may experience from the Vaccine, and I have carefully read and understood this statement. I have had the opportunity to ask the Wellspring Pharmacy pharmacist any questions regarding the Vaccine or the information in the Vaccine Information Statement, and my questions have been satisfactorily answered. I have truthfully answered all questions regarding my medical history listed above. I understand that if I answered any question with a “Yes,” there is a higher likelihood of experiencing an adverse reaction from the Vaccine. After careful consideration, I believe the benefits of receiving the Vaccine outweigh the associated risks, and I have decided to have the Wellspring Pharmacy pharmacist administer it to me. If applicable, I authorize Wellspring Pharmacy to submit a claim to my insurer for this health care service and assign my insurance benefits under such claim to Wellspring Pharmacy. I will be financially responsible for any copays, coinsurance, and deductibles for the requested services, as well as for any services not covered by my insurance benefits. I authorize Wellspring Pharmacy to use and/or disclose my information, including any medical-related information I provide or that is created or received by Wellspring Pharmacy, as necessary for payment, treatment, or health care operations. This authorization includes disclosures to regulatory agencies, Medicare, Medicaid, health plans, pharmacy benefit managers, claims processors, billing companies, interpreters, and others involved in my treatment, as well as any state immunization registry. Wellspring Pharmacy shall not be liable, responsible, or accountable for any loss, injury, death, or damage suffered by me or any other person in connection with the administration of the Vaccine by the Wellspring pharmacist. I, for myself, my heirs, executors, personal representatives, and assigns, hereby release Wellspring Pharmacy, its employees and contractors, specifically the administering pharmacist, its agents, or representatives from any and all claims arising out of, in connection with, or related to my receipt of the Vaccine from Wellspring Pharmacy as allowed by applicable law. By signing below, I certify that I am the patient or the patient’s guardian/personal representative signing on behalf of the patient, and that I have read, understood, and agree to all statements on this form.