Hurricane Family Pharmacy Form Page

Patient Information:

First Name

Last Name

Email Address

Mobile Number

Address

City

State

Zip Code

Date of Birth

Gender

Race

Allergies

Primary Care Physician

Primary Care Phone Number

Insurance Information:

Bin #

ID #

Group #

PCN

Medicare Information:

ID #

Name on Card

Consent:

Booking Status

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I have read, or have had read to me, the written information regarding the vaccine(s) being administered. 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 have received a copy of a current Vaccine Information Sheet. I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Mutual Member Drug Store to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Mutual Drug, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s).