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Child and Family Agency

Child and Family Agency

Strong | Safe | Supported

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VACCINE CONSENT FORM-SPANISH


"*" indicates required fields

Consentimiento para la Administración de Vacunas

Información de la persona que RECIBIRA LA (S) VACUNA (S)

Nombre*
MM slash DD slash YYYY
Dirección*
Relación al paciente*
Nombre del padre/tutor*
Vacunas que se administrara, marque todo lo que corresponda.*
Declaración de información sobre vacunas (VIS)
DTaP: difteria, tétanos, tos ferina (https://www.immunize.org/vis/spanish_dtap.pdf)
Hib: Haemophilus Influenza tipo b (https://www.immunize.org/vis/spanish_hib.pdf)
Tdap: Tétanos difteria, tos ferina (https://www.immunize.org/vis/spanish_tdap.pdf)
Td : Tétanos, difteria (https://www.immunize.org/vis/spanish_td.pdf)
MMRV : sarampión, paperas, rubeola varicella (https://www.immunize.org/vis/spanish_mmrv.pdf)
MMR: sarampión, paperas, rubeola (https://www.immunize.org/vis/spanish_mmr.pdf)
PCV: Conjugado neumocócico (https://www.immunize.org/vis/spanish_pcv.pdf)
Varicela (https://www.immunize.org/vis/spanish_varicella.pdf)
IPV: Polio (https://www.immunize.org/vis/spanish_polio_ipv.pdf)
Hepatitis A (https://www.immunize.org/vis/spanish_hepatitis_a.pdf)
Hepatitis B (https://www.immunize.org/vis/spanish_hepatitis_b.pdf)
HPV-9: Virus del Papiloma Humano (https://www.immunize.org/vis/spanish_hpv.pdf)
Meningococo MCV (https://www.immunize.org/vis/spanish_meningococcal.pdf)
Serogrupo B Meningococo (https://www.immunize.org/vis/spanish_meningococcal_b.pdf)
Consentimiento para Servicios*
Para visitas a la Clínica Community Bridge:Doy permiso para que mi seguro sea facturado en el momento de la visita. Entiendo que habrá una escala móvil disponible para aquellos que no tengan seguro. Autorizo la divulgación de cualquier información médica necesaria para procesar mi reclamo. También autorizo el pago de beneficios de salud a Child & Family Agency por los servicios dados. Entiendo y reconozco que he leído y entiendo este consentimiento.
MM slash DD slash YYYY
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