Maternal Immunization Consent Form

Patient Information

Name: Date of Birth: Address: Phone Number: Emergency Contact Name & Phone:

Pregnancy Information

Gestational Age (weeks): Expected Delivery Date: Healthcare Provider Name:

Vaccine Information

Vaccine Name: Date of Vaccination: Manufacturer/Lot Number:

Screening Questions

Details (if any):

Consent

I have read or have had explained to me the information regarding maternal immunization. I have had a chance to ask questions, and these were answered to my satisfaction. I consent to receive the vaccine.