Vaccines

I have read, or have had explained to me, the information regarding the vaccine(s) marked below. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and authorize the administration of the vaccine to me or the person named below for whom I am authorized to make this decision.

I, for myself, my heirs, and executors release Melvindale Pharmacy, Part B Specialists as the Medicare provider, any retail or external site, physician, and employees, from any and all claims arising out of, or in any way related to my receipt of this or these immunization(s). Melvindale Pharmacy and the aforementioned related parties shall not at any time or any extent be liable or responsible for any loss, injury, death, or damage to be suffered or sustained at any time as a result of this vaccination program.

I consent the release of this information to my Primary Care Physician as listed above to document receipt of vaccination.
I agree to wait in the vaccination location for approximately 20 minutes for observation after vaccination.

I authorize Melvindale Pharmacy and Part B Specialists to release information and request payment. I certify that the information given by me in applying for payment under Medicare is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf to Part B Specialists as my Medicare Part B provider.

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