Adult Immunization Informed Consent Form
Patient Information
Full Name
Date of Birth
Address
Phone Number
Email Address
Vaccine Information
Vaccine to be Administered
Date of Vaccination
Health Screening
Are you feeling sick today?
Do you have allergies to medications, food, vaccine, or latex?
Have you ever had a serious reaction to a vaccine?
Do you have a weakened immune system, take immunosuppressive drugs, or undergo therapy?
For women: Are you pregnant or breastfeeding?
Other relevant health information
Consent & Acknowledgement
I have read and understood the information provided about the vaccine. I have had an opportunity to ask questions. I consent to receive the vaccine.
I agree
Signature of Patient
Date
For Clinic Use Only
Name of Vaccine Administrator
Signature
Date