To be signed by adults utilizing Brydge Health’s (“Brydge”) COVID-19 vaccination appointment services.
By signing this form, I represent that I understand that Brydge assists individuals by scheduling appointments to receive COVID-19 vaccinations from local health care providers in the community. I acknowledge that Brydge is not a health care provider, is not involved in the storage, handling, selection, procurement or administration of the COVID-19 vaccine, and makes no guarantees about the vaccine’s efficacy. I understand that there are potential risks of which I may or may not presently be aware associated with my receipt of the COVID vaccine, including, but not limited to, anaphylaxis or other allergic reaction, fever, and flu-like symptoms, and that I have discussed all of such risks and my questions and concerns with a health care provider.
I further acknowledge that, although Brydge will use its best efforts to coordinate effectively with local health care providers, Brydge has no control over vaccine supply and I am not guaranteed to receive a vaccination by using Brydge’s services whether or not I am scheduled to be vaccinated. If, for any reason, I am unable to receive a vaccination after scheduling an appointment through Brydge, I can contact Brydge to schedule a new appointment, or I can utilize a different service or contact a health care provider directly. If for any reason I cannot make my appointment, I agree to contact Brydge immediately to let them know.
Brydge will collect information from me that is necessary for it to provide the services, such as name, address, date of birth and phone number and shall only use such information for purposes of providing the services and Brydge makes will no representation or warranty as to the to protection or disclosure of the information collected.
I voluntarily elect to utilize Brydge’s services and schedule an appointment to receive a COVID-19 vaccination and as a condition of using these services agree to the waiver and release of liability as set forth below.
Waiver and Release of Liability:
In consideration for being allowed to participate in Brydge’s services, on behalf of myself, my personal representatives, heirs, next of kin, successors and assigns, I forever waive, release, and discharge Brydge Health and its agencies, officers, directors, board of trustees and employees from any and all liability for my disability, death, personal injury, disclosure of my personal information or claims of any nature, including all costs and attorneys’ fees, which may hereafter accrue to me resulting from my use of Brydge’s services, Brydge’s disclosure of my personal information or my receipt of, or failure to receive, the COVID-19 vaccination; and I affirm that I am at least 18 years of age and am voluntarily signing this agreement. I have read this form and have had all of my questions and concerns related to Brydge’s services answered, and I fully understand the content of this form.