CONSENT FOR VACCINATION: I have read, had explained to me, or declined the Vaccine Information Statement for the(se) vaccine(s I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) requested and ask that the vaccine(s) be given to the person named above. I, on behalf of myself, my heirs, executors, and personal representatives hereby agree to release, indemnify, and hold harmless Tosa Pediatrics, its subsidiaries, affiliates, agents, owners, providers, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine. I understand that a record of this immunization may be shared through the Wisconsin Immunization Registry (WIR) and with other health care providers directly involved with the vaccinated person's care. A copy of this consent form is as valid as the original.