Vaccine Consent Form

Vaccine Consent Form

A Vaccine Consent Form is used when a person will be receiving a vaccination to provide a record of the vaccine and that the person consents to receive it. This form can be signed by an adult for themselves or as a representative for a minor. A Vaccine Consent Form template can be downloaded below.

Alternate Name:

  • Flu Shot Form.

To create a Vaccine Consent Form, include the following:

  1. The person's name, personal details (such as age, ethnicity, and sex), and contact information.
  2. A set of questions asking the person if they are currently experiencing any signs of illness or could be pregnant.
  3. An additional set of questions about potential health issues the person may have related to receiving a vaccine. For example, certain allergies, bleeding disorders, or other issues will need to be listed in case the person experiences severe side effects after the injection.
  4. Several statements of consent that the person (or representative) asserts. These consent statements acknowledge the person is an adult or has an adult present, the FDA status of the vaccine given, it is possible to experience side effects after receiving the vaccine and what to do if a severe reaction occurs, and the person has been instructed of their rights to privacy by a staff member before receiving the vaccine.
  5. A signature and date section for the person and adult representative (if necessary).
  6. The bottom of the document should include the manufacturer's information about the vaccine and the address where the vaccine was given.

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Download Vaccine Consent Form

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