I certify that I am:

1- The patient and at least 18 years of age; 

2- The parent or legal guardian of the minor Patient: or

3- The legal guardian of the Patient. Further I hereby give my consent to the healthcare provider of Sierra Pharmacy to administer the vaccine(s) I have requested. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccines. I understand the risks and benefits associated with the requested vaccines and have received and understand the Vaccine Information Sheet for these vaccines. I also acknowledge that I have had chance to ask questions and that such questions were answered to my satisfaction. Further I acknowledge that I have been advised to remain near the vaccination area for 15 minutes for observation by the administering health care provider. On behalf of myself, my heirs, and personal representatives, I hereby release and hold harmless Sierra Pharmacy, its staff, agents and employees from any all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of these vaccines. I authorize Sierra Pharmacy to release any medical or other information to my health care professionals, Medicare, Medicaid, or other third party payor necessary to effectuate care or payment and request that payment of authorized benefits be made to Sierra Pharmacy with respect to the vaccine(s) received. If it is determined that this vaccine is not a covered benefit, Sierra Pharmacy may bill me directly for the vaccine and administration.