Review current VIS sheets at https://www.cdc.gov/vaccines/hcp/vis/current-vis.html

 By signing below, you are stating the following:

• I have reviewed the information in the "Vaccine Information Statement(s),"  where applicable, for the vaccine(s) indicated below. I have had a chance to ask questions and had them answered to my satisfaction. I understand the benefits and risks of the vaccine(s) requested and ask that the vaccine(s) currently due for which I have signed below be given to me or to the person named above for whom I am authorized pursuant to Section 431.058, RSMo to make this request.
• I am acknowledging that I have completed the information to the best of my knowledge.
• I acknowledge that my child will be vaccinated by the staff from Saline County Health Department. Parents are welcome to be present, but not required.
• By signing below I am giving consent for myself or minor to receive any treatment as deemed necessary by the attending health care provider.
  SCHD proved services without regard to religion, race, color, national origin, handicapping condition, age, sex, number of pregnancies, or marital
  status.
• We are committed to protecting your personal health information in compliance with the law. By signing belowing you are acknowledging that you have ready and agre with SCHD privacy statement and understand that at any time upon request, you may obtain a copy of SCHD Statement of Privacy Practices.
• I acknowledge receipt of medical services and authorize the release of the information necessary to process this claim for health care service payment and for the purpose of any audits related to payment of this claim.