Healthcare IMV Site

HEALTHCARE IMV SITE

This form documents informed consent for intramuscular vaccine administration and the specific intramuscular vaccination (IMV) site selected for administration. The patient acknowledges receipt of information regarding the vaccine, known common risks and benefits, potential contraindications, and the right to ask questions and refuse or withdraw consent at any time prior to administration. By signing below the patient authorizes administration of the vaccine and the release of immunization information to healthcare providers as necessary for treatment and medical record continuity.

Patient Information

Date of Birth:    Gender: Male Female Other Decline to State

Insurance / Payer Information

Medical History & Screening

Current medications (include blood thinners):

Known allergies (medications, latex, vaccine components):

Are you currently pregnant, breastfeeding, or planning pregnancy in the near future?
Pregnant Breastfeeding None / Not applicable

Screening items — check Yes or No for each item to indicate current status:

Fever or acute illness today? Yes No

History of Guillain-Barré syndrome? Yes No

Use of anticoagulant or bleeding disorder? Yes No

Received another vaccine within the last 14 days? Yes No

Vaccine Administration Details (To be completed by clinician)

IM Site Selection

Indicate the anatomical site selected for intramuscular injection (check one):
Left Deltoid    Right Deltoid    Left Vastus Lateralis    Right Vastus Lateralis
Gluteal (if clinically indicated)    Other:

Risks, Benefits, and Acknowledgment

Benefits: Vaccination reduces the risk of infection and associated complications from the target pathogen. No vaccine provides absolute protection.

Risks: Common side effects include soreness at the injection site, mild fever, fatigue, headache. Rare but serious adverse events may occur, including severe allergic reactions. The patient affirms they have been given an opportunity to discuss benefits and risks and to ask questions.

Right to Withdraw: The patient may refuse or withdraw consent for vaccination at any time prior to administration without penalty or loss of benefits. Withdrawal after administration does not negate documentation of the vaccine given for medical records.

Authorization to Release Immunization Information & HIPAA Acknowledgment

By signing below the patient authorizes the release of immunization data to other healthcare providers and authorized public health entities as required for continuity of care and public health reporting. This authorization includes relevant medical history and the vaccine administration details entered on this form. This authorization expires on the date indicated below or upon written revocation, except to the extent that action has already been taken in reliance on this authorization.

The patient understands that records containing immunization information will be maintained in the patient's medical record and may be shared with other providers and authorized entities in accordance with applicable law. The patient may request a copy of their immunization record.

Additional Notes / Observations

Sign Now