Consent for Immunization Administration Form

Patient Information

Full Name: Date of Birth: Address: Phone Number: Email:

Parent/Guardian Information (if applicable)

Name: Relationship to Patient: Phone Number:

Immunization Information

Vaccine Name: Dose (if applicable): Date of Administration:

Health Screening

Are you currently ill?

Do you have any allergies to vaccines or medications?

Have you had any reaction to previous vaccinations?

Are you currently taking any medications?

Are you pregnant or breastfeeding?

Consent

I have read or have had explained to me information about the vaccine, and fully understand the benefits and risks. I give my consent for the immunization administration.

Signature:

Date: