CBC Vaccine Consent Consent to Vaccination Child's Name* First Middle inital Last Child's Date of Birth* MM slash DD slash YYYY Child's Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child's Primary Care Provider* Check all vaccinations that apply to be given* Dtap: diphtheria, tetanus, pertussis Hepatitis A Hepatitis B HPV-9: human papilloma virus IPV: polio MCV: meningococcal Meningococcal serotype B MMR: measles, mumps, rubella MMRV: measles, mumps, rubella, varicella Tdap: tetanus, diphtheria, pertussis Td: tetanus Varicella Other List other vaccines to be given*Consent for Service* I have read or have had explained to me the information included in the Vaccination Information Statement(s) for the vaccinations selected above. I have had a chance to ask questions that were answered to my satisfaction. I believe that I understand the benefits and risks of the vaccinations and ask that the vaccine dose and/or series be given to me or the person named above for whom I am authorized to make this request. I also give permission for this vaccination to be reported to the primary care provider listed above. Parent/Guardian signature* Date* MM slash DD slash YYYY
