Click on the image below of the vaccine(s) you wish to receive to view the vaccine information sheet.
By signing below,
I understand the benefits and risks of the vaccine as described in the Vaccine Information Statement (VIS) that is available by clicking on the image above representing the vaccine I wish to recieve.
I have received a copy of the notice of privacy practices Click here for Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Vaccine / Lot / Date / Exp Admin Site
R / L Arm
Signature of Pharmacist/Technician who administered vaccine.
______________________________________________ Date ___/___/______