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Vaccine Consent Form

To download a paper copy of this form, please click here.

Patient Info

Insurance Info

Please answer the health questions below.
Please acknowledge the following:
I have read or have had explained to me written information about the vaccine listed below. I have had an opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine being administered and authorize the administration of the vaccine to me or the person named below for whom I am authorized to make this decision.

For Patients receiving Live Vaccines only: I further certify that I have read the list of contraindications to the vaccine[s] set forth above and neither me or my Ward have a contraindication to the vaccine[s] to be administered.
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