Vaccine Consent Form (rev 20221003) "*" indicates required fields Patient's Name* First Last Date of Birth* MM slash DD slash YYYY Primary Care Provider* Patient is* Self Child Child's School* School Grade* Parent/Guardian Name* First Last Parent Guardian Phone number*Check all vaccinations that apply to be given* Dtap: diphtheria, tetanus, pertussis Hepatitis A Hepatitis B Hib: Haemophilus Influenza type b HPV-9: human papilloma virus IPV: polio MCV: meningococcal Meningococcal serotype B MMR: measles, mumps, rubella MMRV: measles, mumps, rubella, varicella PCV: Pneumococcal Conjugate Tdap: tetanus, diphtheria, pertussis Td: tetanus Varicella Vaccine Information StatementDtap: diphtheria, tetanus, pertussis (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/dtap.pdf) Hepatitis A (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-a.pdf) Hepatitis B (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.pdf) Hib: Haemophilus Influenza type b (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hib.pdf) HPV-9: human papilloma virus (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hpv.pdf) IPV: polio (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/ipv.pdf) MCV: meningococcal (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening.pdf ) Meningococcal serotype B (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening-serogroup.pdf) MMR: measles, mumps, rubella (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mmr.pdf ) MMRV: measles, mumps, rubella, varicella (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mmrv.pdf ) PCV: Pneumococcal Conjugate (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv.pdf ) Tdap: tetanus, diphtheria, pertussis (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/tdap.pdf ) Td: tetanus (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/td.pdf) Varicella (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/varicella.pdf) 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. For Community Bridge Clinic Visits: I give permission for my insurance to be billed at time of visit. I understand that a sliding scale will be available for those without insurance. I authorize the release of any medical information necessary to process my claim. I also authorize payment of health benefits to Child & Family Agency for services provided. I understand and acknowledge that I have read and understand this consent.Signature* Relationship to Patient if <18 years of age Date* MM slash DD slash YYYY
