Have you ever had a serious reaction after receiving a vaccination? For example: anaphylaxis (severe allergic reaction), Guillain-Barré Syndrome (a type of temporary severe muscle weakness)* Do you have any allergies to medications, foods, or vaccines? For example: eggs, gelatin, thimerosal, neomycin, gentamicin, yeast, or latex?* Do you have a history of seizure, brain problems, or nerve problems related to vaccination?* Do you have an autoimmune condition or have taken immune suppressing medications? (Prednisone or other steroids, anticancer drugs, drugs for rheumatoid arthritis, Crohn's disease, or psoriasis)* For women: Are you breastfeeding, pregnant or planning pregnancy in the next month? If you are receiving a Covid-19 vaccine, have you had a severe allergic reaction to a component of a Covid-19 vaccine or to a previous Covid-19 vaccine?

I have not had symptoms of or positive confirmation of Covid-19 in the past 14 days. I meet any of the criteria above as a person any who should not be vaccinated listed above. I have received and read the information sheet for the flu vaccination, which I wish to receive, and have had an opportunity to ask questions. I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the information on the vaccine(s) I have elected to receive which is necessary for me to make an informed decision to receive the vaccine(s). I accept that services might be rendered in a non-private setting. I hereby consent to the administration of the flu vaccine. Furthermore, I hereby release and discharge for myself, my heirs, executors, administrators, and assignees, from any and all claims known or unknown that I (or anyone claiming on my behalf) may have against any Guardian Pharmacy location or entity, its employees and agents in connection with or in any way related to any injury or damages I may suffer as a result of this vaccination. I acknowledge that:(a) I understand the purposes/benefits of my state’s vaccination registry (“State Registry”) and my state’s health information exchange (“State HIE”); and (b) the applicable provider may disclose my vaccination information to the State Registry, to the State HIE, or through the State HIE to the State Registry, or to any state or federal governmental agencies or authorities (“Government Agencies”)as may be required by law, for purposes of public health reporting, or to my healthcare providers enrolled in the State Registry and/or State HIE for purposes of care coordination. I acknowledge that, depending upon my state’s law, I may prevent, by using a state-approved opt-out form or as permitted by my state law, some of these disclosures. I understand that even if I do not consent or if I withdraw my consent, my state’s laws or federal law may permit certain disclosures of my vaccination information to or through the State HIE or to Government Agencies as required or permitted by law. I further authorize the applicable Provider to: (a) release my medical or other information, including any communicable disease (including HIV) and mental health information, to, or through, the State HIE or Government Agencies to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment; (b) submit a claim to my insurer for the above requested items and services; and (c) request payment of authorized benefits be made on my behalf to the applicable Provider with respect to the above requested items and services. I further agree to be fully financially responsible for any cost-sharing amounts, including copays, coinsurance, and deductibles, for the requested items and services, as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service or, if the applicable Provider invoices me after the time of service, upon receipt of such invoice. I request that the vaccine be given to me or to the person named below for whom I am authorized to sign.