I certify that I have received a copy of, read or had explained to me, and understand the CDC Vaccine Information Statement about the vaccination being administered.
All of the information that I have provided above is true and complete to the best of my knowledge, information, and belief. Any questions that had that are relevant to my decision to grant or withhold consent to the vaccine have been answered to my satisfaction I agree to stay in the general area for twenty (20) minutes after receiving my vaccination for medical observation. I authorized the release of any medical information or other information necessary to process an insurance claim if applicable. I also authorize a record of this immunization to be released to my physician and to the Maryland ImmuNet Immunization Registry. I understand and have fully considered the risks, possible side effects, and the potential benefits of the vaccine for the individual named below. My signature below indicates that I am granting to Gregg's Pharmacy and its authorized staff my permission and informed consent to administer the appropriate vaccine to the person named below. I understand that one or two doses may be necessary depending on the person's previous immunization history.