Acknowledgment
I have been given a copy of the Fact Sheet for Recipients and Caregivers for the Emergency Use Authorization (EUA) of the Moderna COVID-19 vaccine and have read it. I have had the chance to ask questions and I am satisfied with the answers and explanations given. I understand that this vaccine has not yet been approved by the Food and Drug Administration (“FDA”), and is being given under an FDA issued EUA. 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 understand the benefits and risks of this vaccine and ask that the vaccine be given to me, or the person for whom I am authorized to make this request. I understand that because this is not an FDA-approved vaccine but is being given under an FDA issued Emergency Use Authorization, KTA, its divisions and affiliates and their respective officers, directors, employees, agents and representatives are immune from civil liability under federal and state law for all claims for loss related to any known or unknown side effects and/or injuries, including but not limited to death, that I, or the person for whom I am authorized to make this request, may experience from this vaccine. This immunity means that if I file a lawsuit against KTA, the court must dismiss any such lawsuit, and the only exception to this immunity is for claims for willful misconduct. 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. In addition, I have received information regarding the Hawaii Immunization Registry (see below).