I voluntarily request and consent that a pharmacist employed by Palms Pharmacy administer to me the vaccine(s) (“Vaccine”) selected above. I acknowledge that Palms Pharmacy has given me a copy of the Vaccine Information Statement that contains information including information on certain adverse reactions that I may experience as a result of receiving the Vaccine, and I have carefully read and understand the Vaccine Information Statement. I have had an opportunity to ask the Palms Pharmacy pharmacist any questions about the Vaccine or about information in the Vaccine Information Statement and my questions have been answered to my satisfaction. I have truthfully answered all the questions regarding my medical history that are listed above. I understand that if I answered a question with a “Yes” there is an increased likelihood that I will experience an adverse reaction from the administration of the Vaccine. After careful consideration, I believe that the benefits of receiving the Vaccine outweigh the risks associated with receiving the Vaccine and I have decided to have the Palms Pharmacy pharmacist administer the Vaccine to me. If applicable, I authorize Palms Pharmacy to submit a claim to my insurer for this health care service and authorize an assignment of my insurance benefits under such claim to Palms Pharmacy. I will be financially responsible for any copays, coinsurance and deductibles for the requested services as well as for any services not covered to my insurance benefits. I authorize Palms Pharmacy to use and/or disclose such information about me, including any medical related information that I provide to Palms Pharmacy or that is created or received by Palms pharmacy that Palms Pharmacy reasonably determines is necessary to receive payment for its services, carry out my treatment or conduct its health care operations. This authorization includes discloses to regulatory agencies, Medicare, Medicaid, health plans, pharmacy benefit managers, claims processors, billing companies, interpreters and other persons involved in my treatment, as well as any state immunization registry. Palms Pharmacy shall not, at any time, or to any extent allowable by applicable law, be liable, responsible, or in any way be accountable for any loss, injury, death, or damage suffered or sustained by me or any other person at any time in connection with, or as a result of, the administration of the Vaccine to me by the Palms pharmacist. I, for myself, my heirs, executors, personal representatives and assigns, hereby release Palms Pharmacy, its employees and contractors, specifically the administering pharmacist, its agents or representatives from any and all claims arising out of, in connection with, or in any way related to my receipt of the Vaccine from Palms Pharmacy as allowed by applicable law. By signing below, I certify that I am the patient or the patient’s guardian/personal representative signing on behalf of the patient, and that I have read, understand and agree to all the statements on this form.