Immunocompromised Patient Vaccine Consent Form
Patient Information
Full Name
Date of Birth
Medical Record Number
Contact Number
Address
Vaccine Information
Vaccine Name
Dose Number
Date of Vaccination
Administration Site
Health Screening
Are you currently ill or experiencing symptoms?
List current medications (including immunosuppressants):
Allergies
Consent
I understand the potential risks and benefits of receiving the vaccine as an immunocompromised individual. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
I give my consent to receive the vaccine.
Patient/Guardian Signature
Date
Healthcare Provider Name
Healthcare Provider Signature
Date