Immunization Consent Form

Immunization Consent Form
A vaccine, albeit known to be a preventive measure against viruses and diseases, may have adverse effects on the human body such as allergic reactions. Symptoms may appear in a form of itching, swelling at the part of the body where the vaccine was injected, redness, or tenderness. Other symptoms may include fever, muscle pains, or malaise. These symptoms may happen 6 to 12 hours after administration of the vaccine and may persist until a couple of days. Other hypersensitive reactions may occur as well such as hives, asthma, or systemic anaphylaxis. These reactions may result from hypersensitivity from eggs. Thus, if a person is allergic to eggs, he or she must not be given vaccines that contain eggs.
This risk of causing serious harm is small. However, in case of any severe reaction such as fever, difficulty in breathing, increased heartbeat, dizziness, please see a doctor right away.
Please answer the questions below for evaluation for your qualification to receive vaccination.
Do you currently have a fever?
YesNo
Do you have any allergy to vaccine or any medication, latex, or eggs?
YesNo
Have you ever had a serious reaction after receiving a vaccination?
YesNo
Please list down the vaccines you are allergic to as well as the reaction of your body
Are you suffering from any chronic or metabolic disease such as heart disease, lung disease, asthma, kidney disease, blood disorder, immune system problem such as cancer, leukemia, HIV, etc.?
YesNo
Have you had an X-ray treatments in the past 3 months?
YesNo
Have you recently taken any cancer treatment drugs or steroids?
YesNo
Are you pregnant or planning to be pregnant in the next six months?
YesNo
Have you received any blood transfusion within the past year?
YesNo
Have you received any blood transfusion within the past year?
YesNo
COVID-19 INFORMED CONSENT
I understand that COVID-19 is an extremely contagious disease that has been declared a global pandemic by the World Health Organization (WHO). I likewise understand that there are carriers of the disease that may not show any symptoms and may still cause to spread the virus.
I confirm that I do not have:
FeverCoughSore throatShortness of breathRunny noseLoss of taste or smell
I confirm that:
I have not traveled outside the country in the past 14 daysI have not been exposed to any person who is under observation for COVID-19 infectionI have not been exposed to any person infected with COVID-19
ACKNOWLEDGEMENT
I hereby declare that I have received a copy of the vaccine information material. I have been informed about the benefits and risks of receiving the vaccination. I have had the opportunity to ask questions about immunization all were answered to me to my satisfaction.
I understand that I have the option to defer my treatment to a later date or refuse the treatment. I am fully aware that it is not possible to consider every complication to care. Nonetheless, I am willfully and voluntarily assuming the risk and responsibility for my actions and consequences that may result from my receiving of immunization.
Name
First NameLast Name
Age/Legal Capacity to give Consent
I hereby declare that I am at least 18-years of age with full capacity to give consent.I am a legal representative of the above-named individual and I am signing this form for and on his/her behalf.
Signature
Clear
Date
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Date
Name of Representative
First NameLast Name
Signature
Clear
Date
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Date
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