A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of a vaccine causing serious harm or death is extremely small. I have read the information about the vaccine(s) I am receiving. I have had a chance to ask questions which were answered to my satisfaction. I believe the benefits of vaccination outweigh the risks and I voluntarily request that the vaccine(s) be given to me or the person named as my ward. I authorize Lutz Pharmacy to share my vaccination record with my primary care provider and the Florida immunization registry (SHOTS/IIMS) as required by law.