Consent: Please review the statement below confirming your consent for vaccination and provide the information requested
I have read, or had explained to me, the Vaccine Information Statement for the vaccine(s) I am receiving today.
I understand the risks and benefits, and have been provided an opportunity to ask questions, which have been answered to my satisfaction. I wish to receive the vaccine(s) and hereby give consent for the pharmacist to administer the vaccine(s) and communicate the administration of the vaccine(s) to my primary care practitioner listed above and to the state immunization registry.