I have read, or have had read to me, the written information regarding the vaccine(s) marked below. I have had the opportunity to ask questions that were answered tomy satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet for each vaccine Iam receiving today. I, on behalf of myself, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Gates Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in anyway related to the administration of the vaccine(s) marked below. If under 18 years old, signature by parent or guardian is required.
I AGREE TO WAIT NEAR THEVACCINATION LOCATION FOR APPROXIMATELY 15 MINUTES FOR OBSERVATION BY THE PHARMACY STAFF/PHARMACIST.