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 lnformation Sheet. l, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless V-Care Pharmacy, its subsidiaries, divisions, afiiliates, 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 ol the vaccine(s). I certity that I am at least 18 years old and hereby give my consent to the pharmacists of V-Care Pharmacy to administer the vaccine(s). lf 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.
Pharmacy Benefits/Insurance Card: