Emergency Contact: blanks Phone: blank
Primary Care Doctor: blanks
Consent to Vaccination:
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Bay Street Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists or licensed pharmacy interns of this pharmacy to administer the vaccine(s). If under 18 years old signature by parent or gaurdian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.