MY CONSENT: I have read, or have had read to me, the Center for Disease Control About My Vaccine: CDC Current Vaccine Information Statements regarding the vaccine I am about to receive. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine. I consent to, or give consent for, the administration of the vaccine and the notification of my primary care physician and immunization registry, as applicable. I fully release and discharge VIVA Pharmacy and Wellness officers, directors and employees from any liability for illness, injury, loss or damage which may result there from. I authorize the release of any medical or other information necessary to process this claim. I understand there may be a cost to the vaccine I am receiving today if it is no the COVID-19 Vaccine. I authorize VIVA Pharmacy and Wellness to use my name and email contact information to communicate with me regarding the services performed. I authorize VIVA Pharmacy and Wellness to share my name and insurance information with one another for treatment and payment purposes in connection with the services provided today. Additionally, I understand that I should remain on the premises for 15 minutes for observation in case there is an adverse reaction.