Pediatric Vaccine Informed Consent Form
Patient Information
Child's Name
Date of Birth
Parent/Guardian Name
Relationship to Patient
Vaccine Information
Vaccine Name
Dose Number
Date to be Administered
Health Screening
Has the child had a serious reaction to a vaccine before?
Yes
No
Is the child currently sick or running a fever?
Yes
No
List any known allergies
Consent and Acknowledgement
I have read and understand the information provided to me regarding the vaccine. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction.
I consent to the vaccination
Parent/Guardian Signature
Date