COVID-19 Vaccine Informed Consent Agreement

COVID-19 Vaccine - Informed Consent Agreement

Please carefully read the following informed consent in its entirety.

COVID-19 is an infectious illness caused by a newly discovered coronavirus. For many, the illness is mild or does not produce symptoms; however, in some others, including the elderly and those with underlying medical problems (such as heart disease, diabetes, chronic respiratory disease, cancer, and others) are more likely to develop a serious illness that may result in hospitalization or even death. We are offering you the voluntary opportunity to get the COVID-19 vaccine to help you keep yourself and others safe by not further spreading the virus.

By selecting the ACKNOWLEDGEMENT checkbox during the registration process for receiving the COVID-19 vaccine, I agree to the following:

  1. I have read the contents of this form in its entirety and voluntarily consent to receive the COVID-19 vaccine.
  2. I authorize the COVID-19 vaccine unit to conduct administration of the COVID-19 vaccine.
  3. I authorize that I received the COVID-19 vaccine to be disclosed to the county, state, or to any other governmental entity as may be required by law or local department of health.
  4. I understand that, as with any vaccination or medical procedure, there is the potential for reactions that could include, but are not limited to: fever, difficulty breathing, blood clots, or death.
  5. I understand that I am not creating a patient relationship with this vaccine unit by participating in getting the vaccine. I understand the vaccine unit is not acting as my medical provider and this vaccine does not replace treatment or advise by my medical provider. I assume complete and full responsibility to receiving the COVID-19 vaccine. I agree I will seek medical advice, care, and treatment from my medical provider if I have questions, concerns, if I have any reaction, or anything related to the vaccine process.
  6. To the fullest extent permitted by law, I hereby release, discharge and hold harmless,,, MD Medical Group LLC, and First Call PPE LLC, including, without limitation, any of its respective officers, partners, directors, employees, representatives, businesses, joint venturers, and agents from any and all claims, losses, costs, fees, liability, litigation and settlement costs, counsel fees, and damages, of whatever kind or nature, arising out of or in connection with any: 1) act or omission or negligence whatsoever, regardless of the merit or outcome, relating to my COVID-19 vaccine or the disclosure of me receiving the COVID-19 vaccine; 2) any reaction or injury I may have from the vaccine; 3) any actions or inactions I may take in reliance on getting the vaccine; and, 4) the storing of any personal information on our website or databases.
  7. I have informed myself about the purpose of the COVID-19 vaccine, procedure to be performed, and potential risks and benefits. I understand that I need to provide information about my health insurance on this website when making an appointment.
  8. I authorize MD Medical Group, First Call PPE, and to release all necessary information to my insurance carrier, and I assign payment of my medical benefits to MD Medical Group and its affiliates. If my insurance company sends payments directly to me, I will return those funds to MD Medical Group through
  9. I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I will be provided an opportunity to ask questions before proceeding with a COVID-19 vaccine and I understand that I can ask any question I want at any time for any reason.
  10. I understand that if I do not wish to continue with the administration of the COVID-19 vaccine, I may decline to receive the vaccine at any time.
  11. I acknowledge, confirm, and attest to the fact that I have the full authority to book this vaccine appointment on behalf of myself and/or on behalf of any other individuals for whom I am scheduling an appointment and that such other individuals have given me the authority to book a vaccine appointment on their behalf. I further confirm and attest under the fullest penalties available by law that if the vaccine documents for other individuals for whom I have booked an appointment are being released directly to me that I have such other individuals' permission and prior approval to receive such results and will provide a copy of such vaccine results to those individuals immediately upon receipt. To the extent that I am signing up a minor for the vaccine, I attest and affirm that I am the parent or legal guardian of such minor individual and have the right to provide informed consent on behalf of such minor. I further confirm that by scheduling an appointment for another individual other than myself, and pursuant to this Informed Consent Agreement, I am waiving on behalf of myself and any individuals for whom I schedule the vaccine appointment, any and all claims, losses, costs, fees, liability, litigation and settlement costs, counsel fees, and damages, of whatever kind or nature, against and First Call PPE LLC, including, without limitation, any of its respective officers, partners, directors, employees, representatives, businesses, joint venturers, and agents, arising out of or in connection with the transmittal or disclosure of test results and including but not limited to any alleged violations of the Health Insurance Portability and Accountability Act (HIPAA). I further attest and confirm that I have provided any other individuals for whom I have scheduled a vaccine appointment with a copy of this Informed Consent Agreement and/or instructed them to review it prior to arriving for their testing appointment.
  12. The answers and information I have provided when booking an appointment for myself or any others is truthful and I understand I am violating laws or potentially performing insurance fraud if not.
  13. I agree to allow and First Call PPE LLC to communicate with me for my vaccine status, future testing, follow ups, or any other reason and that I will receive my communication via the email address or cell phone number provided during the registration process. I also understand that it is possible for incorrect reporting mistakes to happen and will contact for assistance as needed by clicking Contact Us on the bottom of this website.

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