Immunization Consent and Record Form
Patient Information
Full Name
Date of Birth
Address
Contact Number
Emergency Contact Name
Emergency Contact Number
Medical History
Please list any allergies:
Current medications:
Relevant medical conditions:
Immunization Record
Vaccine Name
Date Administered
Lot Number
Administered By
Location
Consent
I confirm that the patient information provided is accurate. I hereby give consent for the individual named above to receive the indicated immunizations.
Signature of Patient / Parent / Guardian
Date:
Healthcare Provider Signature
Date: