CLICK "ADD SIGNATURE" THEN USE YOUR MOUSE OR FINGER TO SIGN
I understand and acknowledge that vaccinations are being provided by licensed personnel through USC Pharmacy.
I hereby release, discharge and hold harmless University of Southern California and USC Pharmacies, and its officers, directors, employees, members, subsidiaries, agents, successors, and assigns from any and all liability that may arise, directly or indirectly, now or in the future, by reason of any injury, damage, loss, or expense incurred in connection with my receiving a vaccination today.
I certify that the information provided above has been completed to the best of my knowledge.
I have reviewed (or will have the opportunity to review) the Emergency Use Authorization (EUA) Fact Sheet for Recipients and Caregivers or Vaccine Information Sheet (VIS), if applicable, and had (or will have) a chance to ask questions that were answered to my satisfaction. I fully understand the possible risks and side effects of vaccinations.
I consent to the vaccination being provided for myself or the person named above for whom I am authorized to make this request.
Unless I decline, I understand that this information will be reported to the California Immunization Registry or CAIR.
I authorize the USC Pharmacies to release information and request payment to my health plan. I certify that the information given by me in applying for payment is correct. I request that the payment of authorized benefits be made on my behalf. To sign, please click "Add signature" then use your mouse or finger to create a signature.