Healthcare Vaccination Agreement

HEALTHCARE VACCINATION AGREEMENT

Patient Information

Patient Name:

Emergency Contact

Insurance Information (if applicable)

Medical History

Vaccination Details (To be completed by provider)

Vaccine Name:

Dose Number:     Administration Date:

Administration Site (e.g., left deltoid):     Route (e.g., IM, SC):

Vaccinator Name / Credentials:

Risks, Benefits, and Acknowledgments

I acknowledge that I have been informed of the potential benefits of the vaccine, which may include decreased risk of infection and complications, and the potential risks and common side effects, which may include local pain, swelling, fever, allergic reactions, and other adverse events. Serious adverse events are rare.

I understand that no warranty or guarantee has been made concerning the results of this vaccination. I have had the opportunity to ask questions about the vaccine and its risks and benefits and those questions have been answered to my satisfaction.

Screening Questions (Check any that apply)

History of severe allergic reaction (anaphylaxis) to a prior dose or vaccine component

Currently experiencing moderate or severe acute illness or fever

Pregnant or planning to become pregnant (if applicable)

Known immunocompromised condition or on immunosuppressive therapy

Authorization and Consent

By signing below I authorize the administration of the vaccine described above to me (or to the patient named above for whom I am legally authorized to sign). I authorize the healthcare provider and clinic staff to administer the vaccine, to record the vaccine in the patient medical record, and to release immunization information to my primary care provider or public health authorities when required by law.

I further authorize billing of my insurance and/or assignment of benefits to the provider for administration of this vaccine. I understand I may be responsible for applicable copays or fees not covered by insurance.

I understand I may withdraw this consent at any time prior to administration by notifying the vaccinator. Withdrawal of consent does not apply retroactively to vaccinations already provided.

Acknowledgment and Certification

I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand the risks and benefits described above and consent to vaccination as indicated. I acknowledge receipt of the vaccine information statement or informational materials provided by the vaccinator.

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