I, Authorize the pharmacy staff of Mannino’s Family Practice Pharmacy to administer the COVID-19 Vaccine to myself/my child or minor of which I am guardian (as applicable). I have been provided the Emergency Use Authorization Fact Sheet and understand the benefits and risks of receiving this vaccine. I understand the possible side effects. I have had the opportunity to ask questions of the pharmacist. I understand that notification of this vaccine administration will be sent to the primary care physician listed above and to the Louisiana Immunization Network for Kids Statewide (LINKS). I have also been given a copy of Mannino’s Pharmacy HIPAA policy. I also authorize Mannino’s Pharmacy to bill Medicare, Medicaid or any other applicable third party on my behalf. In addition, I understand that I am responsible for any deductible or coinsurance not paid by the third party and agree to pay the unpaid amount. I agree to wait near the vaccination area for approximately 20 minutes to be monitored/receive treatment in case of adverse reaction.