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Vaccine Consent Form
"
*
" indicates required fields
Click here to review the Vaccine Consent Form
Client's Name
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
Primary Care Provider
*
Client is
*
Self
Child
Check all vaccinations that apply to be given
*
Dtap: diphtheria, tetanus, pertussis
Hepatitis A
Hepatitis B
Hib: Haemophilus Influenza type b
HPV-9: human papilloma virus
IPV: polio
MCV: meningococcal
Meningococcal serotype B
MMR: measles, mumps, rubella
MMRV: measles, mumps, rubella, varicella
PCV: Pneumococcal Conjugate
Tdap: tetanus, diphtheria, pertussis
Td: tetanus
Varicella
Client (check one)
*
has Private Insurance
has HUSKY/Medicaid
has no insurance
is Native American or Alaskan Native
Vaccine Information Statement
Dtap: diphtheria, tetanus, pertussis (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/dtap.pdf
)
Hepatitis A (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-a.pdf
)
Hepatitis B (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.pdf
)
Hib: Haemophilus Influenza type b (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hib.pdf
)
HPV-9: human papilloma virus (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hpv.pdf
)
IPV: polio (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/ipv.pdf
)
MCV: meningococcal (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening.pdf
)
Meningococcal serotype B (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening-serogroup.pdf
)
MMR: measles, mumps, rubella (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mmr.pdf
)
MMRV: measles, mumps, rubella, varicella (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mmrv.pdf
)
PCV: Pneumococcal Conjugate (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv.pdf
)
Tdap: tetanus, diphtheria, pertussis (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/tdap.pdf
)
Td: tetanus (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/td.pdf
)
Varicella (
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/varicella.pdf
)
Consent for Service
*
I have read or have had explained to me the information included in the Vaccination Information Statement(s) for the vaccinations selected above. I have had a chance to ask questions that were answered to my satisfaction. I believe that I understand the benefits and risks of the vaccinations and ask that the vaccine dose and/or series be given to me or the person named above for whom I am authorized to make this request. I also give permission for this vaccination to be reported to the primary care provider listed above.
For Child & Family Agency Medical Clinic Visits:
I give permission for my insurance to be billed at time of visit. I understand that a sliding scale will be available for those without insurance. I authorize the release of any medical information necessary to process my claim. I also authorize payment of health benefits to Child & Family Agency for services provided. I understand and acknowledge that I have read and understand this consent.
Signature
*
Relationship to Patient if <18 years of age
Date
*
MM slash DD slash YYYY
