I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 5 years of age; or (c) legally authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to Inspire Diagnostics or its agents to administer the COVID-19 vaccine.
I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals either 5 years of age or older or 18 years of age and older; and the emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.
I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.
I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes (or more in specific cases) after administration for observation. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Inspire Diagnostics and its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees 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 the vaccine listed above.
I acknowledge that: (a) I understand the purposes/benefits of the state’s immunization registry and (b) Inspire Diagnostics will include my personal immunization information in the appropriate state registry and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies.
I further authorize Inspire Diagnostics or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for me for the above requested items and services. I assign and request payment of authorized benefits be made on my behalf to Inspire Diagnostics or its agents with respect to the above requested items and services. I understand that any payment for which I am financially responsible is due at the time of service or if Inspire Diagnostics invoices me after the time of service, upon receipt of such invoice.
On behalf of the patient, the patient’s heirs and personal representatives, I hereby waive any claim I may have against Loyola Marymount University, the healthcare professional, and each of their respective governing board, officers, agents, employees, volunteers, and representatives (“Released Parties”) 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 the vaccine(s).
