Vaccination Consent Form

Obtain informed consent before administering vaccines, including allergy screening and medical history review.

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Obtain informed consent before administering vaccines, including allergy screening and medical history review.

Patient Name*

Date of Birth*

Vaccine Requested*

Are you currently feeling ill or have a fever?*

NoYes

Have you ever had a severe allergic reaction to a vaccine or its components?*

NoYes

Do you have any allergies to eggs, latex, or gelatin?*

NoYes

Are you pregnant or planning to become pregnant?*

NoYesNot Applicable

Are you immunocompromised or taking immunosuppressive medications?*

NoYes

I have received and reviewed the Vaccine Information Statement (VIS)*

Yes

Patient / Guardian Signature*

I consent to receive the vaccine listed above

By signing, you agree this constitutes an electronic signature.

Date*

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Vaccination Consent Form - Free Healthcare Template | ZenBuild | ZenBuild