I have read, or have had read to me, the written information regarding the vaccine(s) marked below. 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 a current Vaccine Information Sheet for each vaccine I am receiving today. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify and hold harmless Kilgore Inc, 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 vaccine(s)marked below. I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Kilgore's Medical Pharmacy to administer thevaccine(s)marked below. If under 18 years old signature by parent or guardian required. I HAVE BEEN ADVISED TO WAIT 15 MINUTES FOR OBSERVATION AFTER VACCINE.