• Vaccine Consent Form

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  • Consent

    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 to my satisfaction. I understand the benefits and risks of vaccine(s) being administered and have received a copy of a current Vaccine information Sheet or current emergency Use Authorization (EUA) Fact sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Save-Rite Drugs, Inc., Save-Rite Drugs Brandenburg, Save-Rite Drugs Radcliff and/or Towne and Country 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 vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists or Certified Pharmacy Technician of Save-Rite Drugs, Inc., Save-Rite Drugs Brandenburg, Save-Rite Drugs Radcliff and/or Towne and Country Pharmacy to administer the vaccine(s). I also consent that my vaccination may be administered by a nurse that is operating under their authority by the KY Board of Nursing. If a nurse is administering the vaccine they will be receiving the dispensed vaccine from Save-Rite Drugs, Inc, Save-Rite Drugs Brandenburg, Save-Rite Drugs Radcliff and/or Towne and Country Pharmacy. If under 18 years old, signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist or pharmacy team.
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