I have been given a copy and have had explained, the information in the "Vaccine Information Statement" regarding the vaccine I am receiving today. All my questions concerning the vaccine have been answered to my satisfaction. I understand the benefits and risks of receiving the vaccine and request that it be given to me. I ask that this vaccine be administered by pharmacist, pharmacy intern, or pharmacy technician. I understand my pharmacy may submit this immunization information to the state immunization registry or appropriate healthcare provider