This record will be kept on file at the Macon Co. Health Dept. It will include when the vaccine was given, the name of the vaccine manufacturer, lot number, and injection site. I have read and been offered a copy of the Vaccine Information Statement and have had the opportunity to ask questions and had them answered to my satisfaction. I understand the benefits of receiving the vaccine(s) and give my consent to receive the injection(s). 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 have been offered a copy and/or read the HIPAA Privacy Act and agree to the statements above.