Occ Med Ok LLC, 615 E. Main Street Jenks, Ok. 74037 Consent for injection or Vaccine and acknowledgement of information, \ hereby indicate that | have given consent to Occ Med Ok LLC and its associates or assistants to perform and or administer the following immunizations oF medical evaluation. Patient Name: 01M yal pate of sith: OS 124 [4lp Immunization —Seasonal Flu Shot Signing this form will acknowledge that you request and consent to the above named immunization or examination. | have been informed of the purpose for the injection, and | am aware of the possible side effects and reactions, some of which include: discomfort at or around the injection site, fainting, rash, itching, wheezing, anaphylactic reactions, or damage to nerve, blood vessel, muscle, brain or kidneys. and possible death. understand that | AM TO WAIT 20 MINUTES AFTER MY SHOT BEFORE LEAVING THE SITE. am aware that the possibility and nature of results or complications cannot be anticipated with complete accuracy. | acknowledge that no guarantees, express or implied, have been made as to the results of the above described immunization. hereby state that | have read and understand this request and consent that all my questions about the immunization have been answered and | fully understand the risk and complications of an Immunization. | hereby consent or authorize the administration of the above named vaccination. | Understand all the information was provided to me and hold harmless Occ Med Ok LLC, and its associates, afflliates, assistants, and partners. vate: 20-704 time: _ 50 signature of patient. DOW Wyedo oct 14 2014 Med / dosage 5 lot# 58706 Expires: June 2015