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Please initial the appropriate spaces.

I have read and understand the Vaccine Information Statement(s) for:
_____the Flu Shot

I give my consent for the Nurses of Physico Health Assessments to administer the following vaccine:
_____the Flu Shot

I acknowledge that ON Semiconductor is not liable for the actions of Physico Health Assessments in the storage and administration of any vaccines. Further, Physico Health Assessments is not liable for any untoward effects of the vaccines in so much as the vaccines are stored and administered according to Center for Disease Control (CDC) guidelines.

I know that my health information is protected by Physico Health Assessments under the provisions of The Health Information Portability and Accessibility Act (HIPAA) of 1996, an explanation of which has been made available to me through the company website, physico2go.com, and at the clinic site.

I have been instructed to remain in the presence of the Physico nurses for ten minutes following the administration of the vaccine(s).

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signature                                                                                    date