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,on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold Lindstrom Thrifty White 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 givemyconsent othepharmacists of Lindstrom Thrifty White 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.
Please answer these questions to the best of your ability keeping in mind the safety of staff and other patients using our services.
*These questions are to be answered Yes if your are experiencing more than "Normal" symptoms on a daily basis.