I certify that I am the patient and am at least 18 years of age (or parent/legal guardian of patient). I am providing information on this form that is accurate to the best of my knowledge. I give my consent to the healthcare provider (pharmacist) at Rogue Community Health to administer the vaccination I have requested above. I understand the risks and benefits associated with the vaccine and have received the Vaccine Information Statement relating to the vaccine listed above. I acknowledge that it is advised to remain near the vaccination administration area for at least 15 minutes so I can be monitored by healthcare provider for possible signs of adverse reaction(s). I have received this clinic’s HIPAA Notice of Privacy Practices.