I have been given and read the Emergency Use Authorization (EUA) for the Moderna Vaccine and have had my questions answered about COVID-19 vaccine. I understand the benefits and the risks of the COVID-19 vaccine and ask that the vaccine be given to me. Moderna requires 2 doses, 28 days or more apart, to be fully effective. I agree to obtain the second dose. I consent to the administration of the vaccine by representatives of Legacy Medical Care (LMC). I fully release and discharge LMC, its affiliates and their officers, directors, employees, and persons acting on their behalf or at their direction from any liability or claim related to the administration of, or my receipt of, the vaccine. I authorize the release of my information to be shared with the state or federal registry.