CONSENT
I have read, or have had read to me, t he written information regarding the vaccine(s) I will be receiving. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of current Vaccine Information Sheet. I certify that I am at least 18 years old and hereby give my consent to the pharmacists/authorized technicians of Jarrettsville Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Jarrettsville 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 vaccines. Further, I agree to stay on site for 15 minutes and that:
(1)The information provided is correct
(2)I have read the EUA Fact Sheet provided
(3)All records and required information will be recorded
Click Here to Download the Moderna Emergency Use Authorization (EUA) Fact Sheet