I have read, or had explained to me, the Vaccine Information Statement, Vaccine Information Fact Sheet, and/or Patient Fact Sheet about the vaccination. I have been given an opportunity to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described and I certify the information provided regarding eligibility for the vaccine isaccurate. I request that the vaccination be given to me (or the person named above for whom I am authorized to make this request). I waive and release all claims I, or anyone claiming by or through me, now have or may hereafter acquire against Downtown Pharmacy, and their respective directors, officers, employees, and agents for any damage or injuries if I, or the person named above for whom I am authorized to make this request, contract the disease being vaccinated against, other diseases, or suffer any other adverse reactions following administration of this vaccine. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries. I have received a copy of the Patient Bill of Rights.