I as the client/patient, agree to receive care from a health care provider at The Immunization Clinic. I give consent for examination, immunization, medical advice, and other services from my clinic provider. (2) I acknowledge that I have had the opportunity to read or receive a copy of the appropriate Vaccine Information Statements (s) via the above link. (3) The Immunization Clinic will keep this record in your file and will only share with you and where legally required with the Department of State Health and Human Services and the CDC. It records what vaccine(s) and/or test(s) were given, the date when the vaccine(s) and/or test(s) were given, the name of the company that made the vaccine(s) and/or test(s), the lot number of the vaccine(s) and/or test(s), and the address where the vaccine(s) and/or test(s) were administered. (4) By signing the form below, you hereby freely and voluntarily give your permission and are requesting that the vaccine, TB skin test or lab be obtained as indicated by your signature(s) below be given to you or the person named below for whom you are authorized to make this request. (. You hereby release and agree to hold harmless The Immunization Clinic, its Officers, and Employees for all liability, of any kind or nature whatsoever, which might arise out of or result from any vaccine(s) and/or test(s) administered to you.