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Vaccination Consent Form
Consent

Vaccination Consent Form

2 pages•12 fields•HIPAA-ready
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Vaccination Consent Form

Vaccination Consent Form

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Patient Full Name
Jane Martinez
Date of Birth
03/15/1985
Vaccine(s) Requested
Diabetes
Hypertension
Asthma
Heart Disease
Allergies to Vaccine Components
Diabetes
Hypertension
Asthma
Heart Disease
Currently Pregnant or Immunocompromised
Option A
Option B
Option C
Recent Illness or Fever
Option A
Option B
Option C
Previous Adverse Reaction to Vaccines
Diabetes
Hypertension
Asthma
Heart Disease
VIS Received and Reviewed
Guardian Name (if minor)
Jane Martinez
Consent to Vaccinate
Diabetes
Hypertension
Asthma
Heart Disease
Patient or Guardian Signature
Sign here
Date of Consent
03/15/1985
Submit
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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.

Patient Full NameText
Date of BirthDate
Vaccine(s) RequestedConditions
Allergies to Vaccine ComponentsConditions
Currently Pregnant or ImmunocompromisedMultiple Choice
Recent Illness or FeverMultiple Choice
Previous Adverse Reaction to VaccinesConditions
VIS Received and ReviewedCheckbox
Guardian Name (if minor)Text
Consent to VaccinateConditions
Patient or Guardian SignatureE-Signature
Date of ConsentDate
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