I certify that I am: (a) the patient and at least 18 years of age; or (b) the parent or legal guardian of the patient (‘Ward’). I have received a copy of the applicable Vaccine Information Statement[s] and I have read the adverse reactions associated with the administration of vaccine[s]. Furthermore, I consent to the administration of the vaccine[s] requested above to me or my Ward and acknowledge that, as a condition to administration of the vaccine[s], myself or my Ward must remain under the observation of the administering pharmacist for a period of not less than 15 minutes. I understand that a copy of the vaccine manufacturer’s drug information sheet is available on request. Furthermore, I have also had an opportunity to ask questions about the immunization[s]. I believe the benefits outweigh the risks and I voluntarily assume full responsibility for any reactions that may result from either my receipt of the immunization[s] or the receipt of the immunization[s] by the person named above for whom I am the Ward. My medical record, may be shared with my primary care provider or other healthcare provider and the medical record of my Ward may be shared with his/her primary care provider or other healthcare provider. I, for myself and on behalf of my Ward, and each of our respective heirs, executors, personal representatives and assigns, hereby release Lo Cost Pharmacy, and its affiliates, subsidiaries, divisions, directors, contractors, agents and employees (collectively “Released Parties”), from any and all claims arising out of, in connection with or in any way related to my receipt and the receipt by my Ward of this or these immunization[s]. Neither Lo Cost Pharmacy nor any of the Released Parties shall, at any time or to any extent whatsoever, be liable, responsible or in any way accountable for any loss, injury, death or damage suffered or sustained by any person at any time in connection with or as a result of this vaccine program or the administration of the vaccine[s] described above. I authorize Lo Cost Pharmacy to (a) notify my or my Ward’s primary care provider of the vaccine administered and to provide same with copies of all vaccination records; (b) to enter my or my Ward’s vaccine information on the Georgia Registry of Immunization Transactions; and (3) make any other disclosures required by law. Lo Cost Pharmacy will use and disclose your personal and health information or the personal and health information of your Ward, to receive payment of the care we provide, and for other health care operations. Healthcare operations generally include those activities performed to improve the quality of care. I acknowledge that I have received a copy of the Notice of Privacy Practices.