If you like that, you'll love these blurbs from the shot waivers
Consent for Use of Protected Health Information & Claims Agreement: I hereby consent to and acknowledge the receipt of a Notice of Privacy Practices regarding the use and disclosure of any personal health information for the purpose of health care operations, along with the assignment of all payment from the insurer listed above to x–x associated with the services contemplated herein. Vaccine authorization: my signature on this form indicates that I have requested that the vaccine indicated below be administered to me by a x–x station or x–x representative. I relieve x–x, the x–x partner, the administering nurse and personnel of any liability for any reactions that should occur. I unconditionally and irrevocably waive any right to a trial by jury, to the maximum extent allowed by law, for any claim or action arising out or related to this service, and that any such claim or action shall be determined solely on an individual basis through arbitration in accordance with Capital Commercial Rules of the American Arbitration Association. Neither I nor x–x shall be entitled to join or consolidate claims in arbitration by or against other individuals or entities or arbitrate any claims as a representative member of a class or in a private attorney general capacity. In the case of occupational exposure, x–x has permission for blood testing for patient and employee safety alike. I have read or had explained to me the information from the Vaccine Information Statement and understand the risks (including adverse events) and benefits of the vaccine. I understand I will be responsible for payment for the below vaccine, these services are not free, and that nonpayment by the insurance company or patient will result in collections for the amount due. Additionally, I understand that if I am I self–pay or no–pay patient receiving services, that all funds should be paid at the time of the service and not to x–x. If consenting for another, I have the legal authority, based on my relationship to the individual indicated above, to consent to this vaccine administration.
CONSENT AND HIPAA PRIVACY INFORMATION: I have read the above Consent and Release and understand its provisions. I understand that participation in this COVID–19 vaccination program is completely voluntary and not required.