Vaccination Consent Form Template

VACCINATION CONSENT FORM

Date: Date

Healthcare Facility/Clinic: Facility Name

Address: Address Phone: Phone

PATIENT/RECIPIENT INFORMATION

Patient Name: Full Name

Date of Birth: DOB

Age: Age

Sex: M/F/Other

Address: Address

Phone: Phone

Email: Email

Parent/Guardian (if patient is a minor):

Name: Name

Relationship: Relationship Phone: Phone

Emergency Contact: Name and Phone

1. VACCINE INFORMATION

Vaccine(s) to be Administered:

Vaccine 1:

• Vaccine Name: e.g., COVID-19 vaccine, Influenza vaccine, Tdap, MMR, etc.
• Manufacturer: Manufacturer name
• Lot Number: Lot number
• Expiration Date: Date
• Dose Number: 1st/2nd/3rd/Booster
• Route: Intramuscular/Subcutaneous/Oral/Intranasal
• Site: Left/Right deltoid, thigh, etc.

Vaccine 2 (if multiple vaccines):

• Vaccine Name: Name
• Manufacturer: Manufacturer
• Lot Number: Lot number
• Expiration Date: Date
• Dose Number: Number
• Route: Route
• Site: Site

2. VACCINE INFORMATION STATEMENT (VIS)

I acknowledge:

• I have received and read (or had read to me) the Vaccine Information Statement(s) for the vaccine(s) I am receiving
• The VIS is dated: VIS Date
• I have had the opportunity to ask questions
• I understand the benefits and risks of the vaccine(s)

VIS documents provided for:

• Vaccine 1 name
• Vaccine 2 name
• Additional vaccines

3. SCREENING QUESTIONS

Please answer the following questions. If you answer YES to any question, it does not necessarily mean you cannot be vaccinated. It means additional questions may be asked. If uncertain, please ask healthcare provider.

For Patient or Parent/Guardian to Complete:

1. Are you feeling sick today? - Yes No

2. Do you have allergies to medications, food, a vaccine component, or latex? - Yes No

- If yes, specify: _______________________

3. Have you ever had a serious reaction after receiving a vaccination? - Yes No

- If yes, specify: _______________________

4. Do you have a long-term health problem (heart disease, lung disease, asthma, kidney disease, metabolic disease, anemia, or another blood disorder)? - Yes No

- If yes, specify: _______________________

5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? - Yes No

6. Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments? - Yes No

7. Have you had a seizure or a brain or nervous system problem? - Yes No

8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug? - Yes No

9. For women: Are you pregnant or is there a chance you could become pregnant during the next month? - Yes No N/A

10. Have you received any vaccinations in the past 4 weeks? - Yes No

- If yes, which vaccine(s) and date: _______________________

Additional Questions for Specific Vaccines (if applicable):

For COVID-19 Vaccine:

11. Have you received another COVID-19 vaccine? - Yes No

- If yes: Vaccine type: _______ Date of last dose: _______

12. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to: - PEG (polyethylene glycol) - Polysorbate

13. Have you received passive antibody therapy (monoclonal antibodies or convalescent plasma) for COVID-19? - Yes No

- If yes, date: _______

For Influenza Vaccine:

14. Do you have an allergy to eggs? - Yes No

15. Have you ever had Guillain-Barré Syndrome (GBS)? - Yes No

4. CONSENT AND AUTHORIZATION

I understand that:

Purpose of Vaccination:

• Vaccination helps protect against serious diseases
• No vaccine is 100% effective
• I may still get the disease even if vaccinated, though symptoms may be milder

Benefits:

• Protection against disease
• Protection of others (community immunity)
• Prevention of serious complications
• Other vaccine-specific benefits

Risks and Side Effects:

Common Side Effects (may include):

• Pain, redness, or swelling at injection site
• Fever
• Fatigue
• Headache
• Muscle aches
• Chills
• Nausea
• Vaccine-specific common side effects

Serious Side Effects (rare):

• Severe allergic reaction (anaphylaxis)
• Vaccine-specific serious risks
• Other severe reactions (very rare)

Unknown Risks:

• For newer vaccines, long-term effects not yet known
• Rare side effects may not yet be identified

Managing Side Effects:

• Most side effects are mild and resolve within a few days
• Over-the-counter pain relievers and fever reducers may be used
• Apply cold compress to injection site
• Drink plenty of fluids
• Rest as needed

Alternative to Vaccination:

• Not receiving the vaccine
• Increased risk of contracting the disease
• Risk of serious complications from the disease

What To Do After Vaccination:

• Remain in waiting area for 15 minutes (or 30 minutes if history of severe allergic reactions)
• Report any severe or concerning reactions immediately
• Seek medical care for:

- Difficulty breathing - Swelling of face or throat - Fast heartbeat - Dizziness or weakness - Hives or rash - High fever (over 104°F) - Other warning signs

Reporting Adverse Events:

• Report to healthcare provider
• Report to Vaccine Adverse Event Reporting System (VAERS):

- Online: https://vaers.hhs.gov - Phone: 1-800-822-7967

• For COVID-19 vaccines, also report to vaccine manufacturer

Vaccine Documentation:

• Vaccination will be recorded in my medical record
• Vaccination card/record will be provided
• Information may be reported to state/local immunization registry
• I am responsible for keeping my vaccination record

Information Sharing:

• Information may be shared with state immunization registry
• May be shared with my primary care provider
• May be shared for public health purposes
• May be required for school, work, or travel

Financial Responsibility:

• Covered by insurance: Yes/No
• Medicare/Medicaid: Accepted/Not accepted
• Self-pay: Cost
• No out-of-pocket cost programs: If applicable

I understand that I may decline vaccination.

5. AUTHORIZATION AND CONSENT

I hereby authorize and consent:

• I authorize administration of the vaccine(s) indicated above
• I have read (or had read to me) the Vaccine Information Statement(s)
• I have had the opportunity to ask questions which were answered to my satisfaction
• I understand the benefits and risks of the vaccine(s)
• I understand the risks of not receiving the vaccine(s)
• I believe the benefits outweigh the risks
• I have answered the screening questions truthfully
• I consent to receiving the vaccine(s)
• I authorize sharing of vaccination information as described
• I authorize reporting to immunization registry
• I authorize billing my insurance (if applicable)

For Minors:

I am the parent or legal guardian of the person named above and I have authority to consent to vaccination.

SIGNATURES:

Patient or Parent/Guardian:

Signature: _______________________

Printed Name: Name Relationship to Patient (if not patient): Self/Parent/Guardian

Date: _______________________

Healthcare Provider Administering Vaccine:

Signature: _______________________

Printed Name: Name

Title: RN/MD/DO/PA/NP/Pharmacist

Date: _______________________

Time: _______________________

FOR HEALTHCARE PROVIDER USE ONLY:

Pre-Vaccination Screening:

• Screening questions reviewed
• Contraindications assessed
• Patient medically cleared for vaccination
• VIS provided (date: VIS date)

Vaccine Administration:

• Vaccine: Name
• Manufacturer: Name
• Lot Number: Number
• Expiration Date: Date
• Dose: Amount mL
• Route: IM/SQ/IN/Oral
• Site: Location
• Time Given: Time
• Administered by: Name and title

Post-Vaccination:

• Observation period completed (15/30 minutes)
• No adverse reactions observed
• Patient tolerated well
• Vaccination card updated
• Next dose due: Date (if applicable)
• Patient education provided
• Follow-up scheduled (if needed)

Adverse Reaction (if any):

• None
• Reaction noted: Description
• Intervention: Actions taken
• VAERS report filed: Yes No

Provider Signature: _______________________

Date: _______________________

PATIENT COPY / MEDICAL RECORD COPY

Keep your vaccination record card in a safe place as proof of vaccination.