A copy of a Vaccine Information Sheet or a fact sheet has been provided to me corresponding to the vaccine that I will receive. I have read the information and I have had the opportunity to ask questions and by which answers were given to me to my satisfaction. I understand that the vaccine has corresponding benefits and risks and I assume full responsibility for its effect or reaction to my body.
I request that the vaccine be given to me or to the above-named patient for whom I am authorized. I have been advised and I understand that I have to remain within the premises for 15 minutes after I have been administered the vaccine.
I understand that in case side effects start to manifest, I shall call my doctor, the pharmacy, and/or 911.
I understand that my health information may be required to be disclosed to the physician responsible for this protocol of gathering information of people vaccinated (if applicable) for the benefit or use of my insurance plan, health services, medical facilities, my physician, federal registries, for the purpose of this and other procedures or treatment. I also understand that this disclosure shall be limited to as previously stated and shall not be used for other purposes not authorized by me.