These terms apply to the administration to you of your service from an authorised facilitator for Community Pharmacy. By consenting to receive the service, you confirm that you have read and agreed to the following terms: 
 

 I confirm and agree the following:          

1. I am at least 18 years of age.
2. I understand that the service is subject to availability.   
3. I have read and understand information on precautions, contraindications and side effects, am aware of and accept any risks associated with the service and to my knowledge I do not suffer from any condition or circumstance that prevents me from having the service or makes it unsafe for me.
4. I will answer truthfully if the nurse asks for specific information about my health, or other conditions that may affect my participation.   
5. I will immediately inform the nurse of any adverse changes I experience in the course of participating in the service or afterwards, including (but not limited to): discomfort, pain, dizziness, shortness of breath, wheezing, difficulty breathing, swelling of the face, lips, tongue or other parts of the body.  
6. I understand that as part of receiving the vaccination, Community Pharmacy must securely retain my record in accordance with HIPAA legislation.   
7. Community Pharmacy and its employees, agents, sub-contractors, directors and related bodies corporate will not be responsible for any injury, loss or damage you suffer from the service (except where liability cannot be excluded by law).                  

Precautions and Contraindications

I agree to let the pharmacist know prior to my service if I:

• am suffering from an acute illness (e.g. an infection) or have a temperature higher than 101.3ºF  
• have or have had an immune response or low immunity problem e.g. a disorder, corticosteroid, cyclosporin or cancer treatment (including radiation therapy)  
• intend to become pregnant, are pregnant or breast-feeding   

I understand that having one of these issues may not prevent me from having the service, but having a discussion with the facilitator beforehand will allow me to make an informed choice about my service.     

Vaccine Information Sheet (VIS)
I have reviewed the appropriate vaccine information sheet provided here. I will address any questions or concerns about the vaccine prior to receiving my immunization with the pharmacist. I should discuss with my pharmacist any possible side effects from my service today, and should immediately seek medical attention should I feel any of the possible side effects discussed.