I understand the benefits and risk of the vaccine(s) being administered and have received a copy of a current vaccine infromation sheet (which will be emailed to you upon submission of this form). I understand that I can ask questions prior to administration of the vaccine and will review the VIS that will be sent to me via email after form submission. I on behalf of my heirs, executors, personal representatives, agents, successors, and assigns herby agree to release, indemnify and hold harmless Milltown Pharmacy, its subsidiaries, divisons, 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. I certify that I am at least 18 years old and here by give consent to pharmacists of Milltown Pharmacy to adminsiter the vaccine. I agree to wait near the vaccination locatio nfor approximately 15 minutes for obeservation by the pharmacist. I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose
of this program is to help remind me when my/my child's immunizations are due and to keep a central record of my/my
child's immunization history.
I understand that the medical information in the NJIIS may be shared with authorized health care providers, schools,
licensed child care centers, colleges, public health agencies, health insurance companies, and others as permitted by New
Jersey Law at N.J.S.A. 26:4-131 et seq. and rules at N.J.A.C. 8:57-3.
I understand that I can get a copy of my/my child's record from my primary health care provider, my local health department,
or the New Jersey Department of Health (NJDOH). The NJDOH may be contacted at the website or telephone number
There is no cost to participate in this program.