I acknowledge that I understand the benefits and risks of the requested vaccination as described in the Vaccine Information Sheet. I confirm that KTA Super Stores, on behalf of its pharmacy operations in all divisions, has answered to my satisfaction all of my questions about the vaccine and the vaccination procedure. I request and consent that the vaccination be given, as I direct KTA, to me. I understand that I am giving KTA permission to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable KTA to process my insurance claims with respect to the vaccination. I, for myself, my heirs, executors and assigns hereby release KTA and its divisions and affiliates and their respective officers, directors, employees, agents and representatives from any and all claims arising out of or in connection with the quality of the above described vaccine as provided by the manufacturer and any negligence of KTA in connection with the related injection of the vaccination. I understand that the laws of my state may affect my remedies in connection with this vaccination.