Measles Outbreak Emergency Consent Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email
Parent/Guardian Information (if applicable)
Parent/Guardian Name
Parent/Guardian Phone Number
Consent
Date of Consent
Relationship to Patient
I give consent for the administration of the Measles vaccine/treatment during the outbreak emergency.
Medical Information
Allergies
Medical Conditions
Emergency Contact
Name
Phone Number
Signature
Date