I have read, or have had read to me, the Emergency Use Authorization or Vaccine Information Statement for the vaccine (see above) 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 being administered.
I further acknowledge that all of the information provided on this form is accurate and has been provided truthfully to ensure that I am receiving my vaccine at the appropriate interval.
I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Gaughn's Drug Store, 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 pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait in the location designated by staff for approximately 15 minutes for observation by the pharmacist and or designated personnel. I have read and reviewed the Notice of Privacy Practices available at www.gaughns.com.