Immunization Screening+Consent

Please read the Vaccine Information Statement which matches the vaccine(s) your child is scheduled to receive today. Then proceed to the following pages for the questionnaire and consent form. Please ask all questions you may have. Thanks very much!
DTaP-Hep B-Polio, HIB, PCV13 (2, 4, 6, months)

Consent for Immunization
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
I have been given a copy and have read, or have had explained to me, the information of the Vaccine Information Sheet (VIS) Provided by the Centers for Disease Control (CDC) for each vaccine I/my child am to receive today.

I have had a chance to ask questions and they have been addressed to me satisfaction.

I understand the benefits and risks of each vaccine to be given.

I give my consent for each of the vaccines to be given to me/my child at this time.
Name of Parent/Guardian/Patient (if over 18 yrs of age): *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Immunization Questionnaire