Immunocompromised Patient Vaccine Consent Form

Patient Information

Full Name: Date of Birth: Medical Record Number: Contact Number: Address:

Medical Information

Primary Diagnosis / Reason for Immunocompromised Status: Current Medications: Allergies (including vaccine-related allergies): Physician/Provider Name:

Vaccine to be Administered

Vaccine Name: Dose Number: Date of Administration:

Consent

I have read and understand the information provided to me regarding the vaccine.

I have had the opportunity to ask questions and they have been answered to my satisfaction.

I voluntarily consent to receive the indicated vaccine.

Patient/Legal Representative Name: Signature: Date:

Provider Verification

Provider Name: Signature: Date: