Vaccination Consent Form

Vaccination Consent Form — Form Fields

This healthcare template includes 11 fields. Obtain informed consent before administering vaccines, including allergy screening and medical history review. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Vaccine Requested (dropdown selection, required) — options: Influenza (Flu), COVID-19, Tdap (Tetanus/Diphtheria/Pertussis), Shingles (Shingrix), Pneumonia, Hepatitis B, Other
• Are you currently feeling ill or have a fever? (multiple choice, required) — options: No, Yes
• Have you ever had a severe allergic reaction to a vaccine or its components? (multiple choice, required) — options: No, Yes
• Do you have any allergies to eggs, latex, or gelatin? (multiple choice, required) — options: No, Yes
• Are you pregnant or planning to become pregnant? (multiple choice, required) — options: No, Yes, Not Applicable
• Are you immunocompromised or taking immunosuppressive medications? (multiple choice, required) — options: No, Yes
• I have received and reviewed the Vaccine Information Statement (VIS) (multiple choice, required) — options: Yes
• Patient / Guardian Signature (signature, required) — I consent to receive the vaccine listed above
• Date (text, required)