Child Vaccine Consent Form
Child Information
Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Teacher's Name
First Name
Last Name
School
Health History
Vaccine History
*
Rows
Yes
No
If Yes, Please Explain
Does your child have any allergies?
1
2
Has your child ever reacted to a vaccine?
3
4
Does your child have a history of fainting or seizures?
5
6
Does your child have a serious medical condition?
7
8
Consent For Immunization
*
Yes, please vaccinate my child
No, please do not vaccinate my child
No, my child already received all the vaccines that are required
Which vaccines did your child have?
Anything you want to add;
Parent/Guardian Signature
Submit
Should be Empty: