I certify that I am the patient and at least 18 years of age. Parent or legal guardian must co-sign for children 3 to 17 years of age. Further, I hereby give my consent to the pharmacist or pharmacy technician of Engleking Rx, LLC to administer the vaccine(s) I have requested. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccines. I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I aslo acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. Further, I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering pharmacist or pharmacy technician. On behalfl of myself, my heirs, and personal representatives, I hereby release and hold harmless Engleking Rx, LLC, it's staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, members, contractors, and emloyees 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) listed. I authorize Engleking Rx, LLC to release any medical or other information to my healthcare professional, Medicare, Medicaid, or other third party payor necessary to effectuate care or payment and requested that payment of authorized benefits be made on my behalf to Engleking Rx, LLC with respect to the vaccine(s) listed. In accordance with Indiana Code 16-38-5-2 all completed vaccination records will be submitted to the state CHIRP registry system within 72 hours. CHIRP allows for the sharing of immunization information authorized health care providers.