CONSENT FOR VACCINATION - YOU MUST SIGN THIS FOR YOUR CHILD TO BE VACCINATED
By signing this form, I give permission for my child to be vaccinated, for my insurance company to be billed for the vaccination(s), and the information about my child's immunization(s) to be entered into the state immunization registry. I also agree that the above information is correct and that:
(1) I have read the current Vaccine Information Statement(s) for the selected vaccine(s) or someone has read it/them to me.
(2) I understand the risks and benefits of getting the selected vaccine(s).
(3) Any questions I had about the vaccine(s) have been answered
This is a required field. Press Save in the upper right corner of the signature box after signing.
*The Signature is required.
Signature of Parent/Legal Guardian *