Immunization Consent Form

Patient Information

Last Name

First Name 

MI

Date of Birth

Gender

Phone Number 

Street Address

City

State

Zip Code

Doctor’s Name 

Phone Number 

Street Address

City

State

Zip Code

Please complete the questionnaire below.

Are you currently feeling unwell?

Please describe:

Do you have any illness or medical conditions?

Please describe

Do you have any  severe allergies? 

Please describe

Have you ever had severe reaction to vaccination in the past? 

Patient Signature

(or Parent/Guardian for minor) 

For Clinic Use Only

Vaccine

Manufacturer

Lot Number

Dosage

Route of Administration

VIS Date

Provider Signature