Rabies Post-Exposure Vaccination Consent Form
Patient Information
Name
Date of Birth
Age
Address
Phone Number
Exposure Information
Date of Exposure
Animal Involved
Location of Exposure
Description of Exposure
Medical History
Allergy to vaccines
Immunocompromised
Pregnant
Currently ill
Other Relevant Medical History
Consent
I have read and understand the information provided to me about rabies post-exposure vaccination. I consent to receive the recommended vaccination.
Signature of Patient/Guardian
Date