Form preview
The Vaccination Consent Form streamlines the immunization process by combining pre-vaccination screening with informed consent documentation in a single form. It is designed to meet CDC and state health department requirements for vaccine administration record-keeping while ensuring patients or guardians provide proper authorization.
This template includes a health screening questionnaire to identify contraindications, fields for specific vaccine information including lot numbers and manufacturer details, and sections where patients acknowledge receiving the Vaccine Information Statement (VIS). It supports documentation for both adult and pediatric immunizations with guardian consent fields.
Used by primary care offices, pharmacies, occupational health clinics, community vaccination sites, and school-based health programs, this form ensures efficient and compliant vaccine administration workflows while maintaining thorough consent documentation.
What's included
- Patient identification and demographics
- Pre-vaccination health screening questionnaire
- Vaccine selection and contraindication checks
- Vaccine Information Statement acknowledgment
- Guardian consent fields for minor patients
- Signature and date capture for authorization
- Medical conditions checklist
Who uses this template
- Screening patients for vaccine contraindications before administration
- Documenting informed consent for flu, COVID-19, or routine immunizations
- Capturing guardian authorization for pediatric vaccinations
- Meeting CDC and state requirements for immunization record-keeping
All form fields
12 fields across 2 pages. Customize any field after signing up.
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