Free Vaccine Consent Form Template
Vaccine Consent Form
Please take a moment to fill out this form before receiving the vaccine.
Name
Date of Birth
Address
Phone Number
Do you have any allergies, chronic medical conditions or are you currently taking any medications?
If yes, please specify
Have you received a vaccine in the past 30 days?
Have you experienced any adverse reactions to vaccines in the past?
If yes, please specify
Consent
By signing below:
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I confirm that the information provided above is accurate to the best of my knowledge.
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I understand the purpose, benefits, and potential risks of the vaccine.
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I consent to receive the vaccine as indicated and agree to any necessary follow-up.
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I release the vaccination provider from liability except for cases of gross negligence.
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I acknowledge that I had an opportunity to ask questions and that they were answered to my satisfaction.
Name:
Date:
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