VACCINE CONSENT FORM – Child and Family Agency

Client's Name*

First Last

Date of Birth*

Primary Care Provider*

Client is*

Self

Child

Other

Client (check one or more):

Has Private Insurance

Has HUSKY/Medicaid

Has no insurance

Is Native American or Alaskan Native

Parent/Guardian’s name (if client <18 years of age)

First Last

Parent/Legal Guardian Phone

School Client Attends

Grade

Check all vaccinations that apply to be given*

Parent/Legal Guardian Signature (if client <18 years of age)

Client Signature*

Date*