This record will be kept on file at the Randolph County Health Department. It will record when the vaccine was given, the name of the manufacturer, the lot number, the injection site, and who gave the injection. A copy of the Vaccine Information Statement will be available to me and I will have had the opportunity to ask questions prior to receiving my immunization. I understand the benefits and risks of the vaccine and give my consent to receive the injection. I give consent for my insurance (if applicable) to be billed, and if denied, I understand that I am responsible for the payment in full. By signing below, I acknowledge that I agree to the HIPAA Privacy Act policy and can request a copy of the said policy from the Randolph County Health Department