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:

              • I confirm that the information provided above is accurate to the best of my knowledge.

              • I understand the purpose, benefits, and potential risks of the vaccine.

              • I consent to receive the vaccine as indicated and agree to any necessary follow-up.

              • I release the vaccination provider from liability except for cases of gross negligence.

              • I acknowledge that I had an opportunity to ask questions and that they were answered to my satisfaction.

              Name:

              Date:

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