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 the current Vaccine Information Sheet. I acknowledge that I understand the purposes/benefits of Texas immunization registry and POPULAR PHARMACY may disclose my immunization information the State Registry. I acknowledge that, depending upon Texas law, I may prevent the disclosure of my immunization information by POPULAR PHARMACY to the Texas Registry by using the opt-out form. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless POPULAR PHARMACY, 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). I certify that I am at least 18 YEARS OLD and hereby give my consent to the pharmacist of POPULAR PHARMACY to administer the vaccine(s). If UNDER 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.