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Child and Family Agency

Child and Family Agency

Strong | Safe | Supported

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    • Community Bridge Clinic
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VACCINE CONSENT FORM


Vaccine Consent Form (rev 20221003)

"*" indicates required fields

Patient's Name*
MM slash DD slash YYYY
Patient is*
Parent/Guardian Name*
Check all vaccinations that apply to be given*
Vaccine Information Statement
Dtap: 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)
Consent for Service*
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.
MM slash DD slash YYYY
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