I have been given and have read, or have had explained to me, the information in the "Vaccine Information Statement(s)" (VIS) for the disease(s) and the vaccine(s) checked on the other side of this sheet. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccines requested and also understand that | have the alternative to decline the vaccine(s I ask that the vaccine(s) signed for be given to me or to the person named for whom I am authorized to make this request. Unless I sign a statement signifying otherwise, I allow immunization information to be entered intotheNew Mexico Statewide Immunization Information System (NMSIIS) and be released to other medical care providers to avoid unnecessary vaccination or to ascertain immunization status. The revised DOH Privacy Policy is at HIPAAPrivacy Brochure (nmhealth.org) will be provided to all student when they receive an immunization.