Name: ________________________________ Date of Birth: _____ / _____ / _________ Age: _____ Phone: (_______)_________________
Address: ____________________________________________ City: ______________ County: ____________, TX Zip Code: ____________
Have you ever received a COVID-19 vaccine? ☐Yes ☐No If yes, manufacturer name: _______________ Date received: _______________
Insurance Carrier Name: _____________________________ ID #: _____________________________ Group #: ______________________
Policy Holder Name (if different): __________________________________ Policy Holder Date of Birth: ____________________________
Social Security Number: ________-_______-_____________ (this is needed by the federal government if you do not have health insurance)
Race: ☐ American Indian or Alaska Native ☐ Asian ☐ Black or African American
☐ Native Hawaiian or Other Pacific Islander ☐ White ☐ Other ☐ Prefer not to disclose
Ethnicity: ☐ Hispanic ☐ Non-Hispanic ☐ Prefer not to disclose
**H-E-B Pharmacy will contact your primary care provider informing them of vaccine(s) given today using the information provided below**
Primary Care Provider Name: _____________________________ Phone: (_______)_________________ Fax: (_______)________________
I hereby give my consent to the H-E-B Pharmacy (“H-E-B”) to administer the vaccine(s) (the “Services”) I have requested below. Section Date: Dec 2020
With my initials, I certify that:
__________ I am: (i) the Patient and at least 18 years of age; (ii) the parent or guardian of the minor Patient; or (iii) the legal guardian of the Patient; or (iv) a person authorized under the
law of another state or a court order to consent for the child; OR
__________ The persons identified under (ii), (iii), or (iv), in the preceding sentence are unavailable and I have authority to consent to the immunization of the child because I am a (i)
grandparent; (ii) adult brother or sister; (iii) adult aunt or uncle; (iv) stepparent; or (v) another adult who has actual care, control, and possession of the child and has written authorization
to consent for the child from a parent, managing conservator, guardian, or other person who, under the law of another state or a court order, may consent for the child; additionally, I
certify that I do not have knowledge of any express refusals or withdrawn authorizations of consent and have not been told not to give consent for the child.
I understand that any Protected Health Information (“PHI”) I provide H-E-B will only be used or disclosed by H-E-B in accordance with H-E-B’s Health Insurance Portability and
Accountability Act (“HIPAA”) Notice of Privacy Practices. By signing below I acknowledge receipt of such HIPAA Notices of Privacy Practices and consent to the uses and disclosures of PHI
described therein. While H-E-B reserves the right to not do so, I consent to H-E-B reporting my immunization information to the State Immunization Registry. Should H-E-B elect to report
my immunization history to the Texas central immunization registry, ImmTrac, I further understand that my immunization information may be accessed by other health care providers,
educators, public health representatives, state agencies and certain insurance payers. I further authorize H-E-B to (1) release my medical or other information to my healthcare
professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment or otherwise, (2) submit a claim to my insurer for the below requested items and
services, and (3) request payment of authorized benefits be made on my behalf to H-E-B with respect to the below requested items and services.
NOT A SUBSTITUTE FOR A PHYSICIAN
I understand that H-E-B Pharmacy representatives are not physicians trained to diagnose and treat medical problems. I acknowledge that the administration of Services does not
constitute, and should not be interpreted as, medical advice or opinions substituting for the advice of a physician. I understand that the administration of Services does not create a doctor-
patient relationship between myself and H-E-B. I agree to consult a physician if I require medical advice or services at any time.
RELEASE, IMDEMNITY AND DISCLAIMER
I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s), including novel COVID-19 vaccine(s). I understand the risks
and benefits associated with novel vaccine(s) and elect to receive a COVID-19 vaccine. I also acknowledge that I have had a chance to ask questions and that such questions were answered
to my satisfaction. I additionally acknowledge that I have received a copy of the H-E-B Pharmacy notice of privacy. 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 health care provider. I understand that in the course of the requested vaccine
administration, an H-E-B Pharmacy representative could possibly be exposed to my blood or bodily fluids. In such event, I agree to review and execute the “H-E-B Post-exposure Consent
for Testing” form.
On behalf of myself, my heirs and personal representatives, I further hereby WAIVE, RELEASE, and AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS (including for costs and
attorney’s fees) H-E-B, its staff, agents, employees and corporate affiliates 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 COVID-19 vaccine(s) and related services, even should such damages or losses result from H-E-B’s negligence.
I have received, read and/or had explained to me the Emergency Use Authorization Fact Sheet or the Vaccination Information Statement for the vaccine I have elected to receive.
s
Patient Signature: _____________________________________________________________________ Date: ______________________________
(Parent or Legal Guardian, if minor)
