I certify that I am the Patient and at least 18 years of age. Further, I hereby give my consent to the health care provider of Bell Healthcare Enterprises, as applicable, to administer the vaccine(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risk and benefits associated with the above vaccine(s) and have received, read, and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering health care provider. On behalf of myself, my heirs, and personal representatives, I hereby release and hold harmless Bell Healthcare Enterprises, as applicable, staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liabilities or claims whether known arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I authorize Bell Healthcare Enterprises, as applicable, to release any medical or other information to my health care professionals, Medicare, Medicaid, or any other third party necessary to effectuate care or payment of authorized benefits be made on my behalf to Bell Healthcare Enterprises, as applicable, with respects to the vaccine(s) listed above.