Health Fair Vaccination Consent Form
Please complete this form to provide your consent and necessary health information for vaccination at the health fair.
Participant's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Which vaccine(s) are you consenting to receive today?
*
Influenza (Flu)
COVID-19
Hepatitis B
Other
Do you have any allergies to medications, vaccines, or food? If yes, please specify.
Are you currently experiencing any illness or fever?
*
Yes
No
Signature of Participant (or Parent/Guardian if under 18)
*
Submit Consent
Submit Consent
Should be Empty: