I acknowledge that I understand the benefits and risks of the requested vaccination as described in the Vaccine Information Sheet or Emergency Use Authorization Fact Sheet, a copy of which is provided with this Consent and Release. I confirm that Dripping Springs Pharmacy has answered to my satisfaction all of my questions about the vaccine and the vaccination procedure. I request and consent that the vaccination be given, as I direct Dripping Springs Pharmacy, either to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release. I understand that I am giving Dripping Springs Pharmacy permission to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company or immunization registry, as applicable, to enable Dripping Springs Pharmacy to process my insurance claims with respect to the vaccination.
I, for myself (and for the recipient of the vaccination, if the recipient is a minor), my heirs, executors, and assigns hereby release Dripping Springs Pharmacy and its affiliates, owners, employees, agents, and representatives from any and all claims arising out of or in connection with the quality of the above-described vaccine(s) as provided by the manufacturer and any negligence of Dripping Springs Pharmacy in connection with the related injection of the vaccination. I understand that the laws of my state may affect my remedies in connection with this vaccination.