Express Lane Vaccination Sign Up Form

I have read the above information or have had the information explained to me. I have had a chance to ask questions and these have been answered to my satisfaction. I understand the benefits and the risks and ask that the vaccine(s) is/are given to me, or to the person named above for whom I am authorized to make this request. I accept responsibility for seeking medical attention for any problems with this vaccination. I authorize billing for the vaccine and its administration to my insurance company and agree to pay any remaining cost up front. I agree to stay in the vaccine administration
area for 15 minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.