Adult Immunization Form (19 Years or Older)

I consent to the administration of the vaccines indicated either to me or to the client named above for whom I am authorized to make this request.  I have read the PRIVACY NOTICE informing me of my privacy rights and Saginaw County Health Department responsibilities.  I understand that at the time of service I will receive a Vaccine Information Statement (VIS) for all vaccines administered, and will have an opportunity to pose questions and have them answered by a registered nurse.  Vaccinations given and recorded on the clinic record can be released to the Michigan Care Improvement Registry (MCIR) and my insurance plan, if applicable. I authorize the Saginaw County Health Department to bill and collect from my insurance for the vaccine and associated administration fee.  I understand that I am responsible for required copayment or deductibles and any other costs associated with vaccination that are not covered by my insurance plan.  I verify that all the above information is correct to the best of my knowledge.