VACCINE CONSENT FORM

Personal Information

IF YOUR SCHOOL'S CLINIC IS WITHIN THE NEXT 2 SCHOOL DAYS, YOUR REGISTRATION MAY NOT BE REVIEWED IN TIME.  YOUR TEEN WILL BE SCHEDULED FOR THE NEXT CLINIC.

Health Insurance Information

Medical Screening for Vaccine Eligibility

Please complete the following: *
 YesNo
1. Does your child have allergies to medications, food, or any vaccine?
2. Has your child ever had a serious reaction to a vaccine in the past?
3. Has your child, a sibling, or a parent ever had a seizure or brain problem?
4. Does your child have cancer, leukemia, HIV/AIDS, or any other immune system condition?
5. Does your child take cortisone, prednisone, steroids or anti-cancer drugs or had radiation treatment?
6. Has your child received a blood transfusion, blood products, or been given immune (gamma) globulin in the past year?
7. Has your child received any vaccinations in the past 4 wks or taken an antiviral drug?

Consent for Vaccination in the School Setting

I have viewed the Vaccine Information Statement(s) for the vaccine(s) requested, using the link below.
I understand the benefits and risks of the vaccine(s) requested.
 
I understand that a record of vaccinations administered in this program will be submitted to the statewide database, KIDSNET within 48 hours of vaccination.  I hereby release The Wellness Company from any and all liability associated with the administration and potential side effects of the vaccine.
 I would like my child to receive this vaccine
Hepatitis A (2 doses)
Hepatitis B (3 doses)
HPV - Gardasil (Human Papillomavirus-3 doses)
MMR (Measles, Mumps & Rubella - 2 doses)
Mening B (Meningococcal)
Meningitis (MCV4)
Polio (3-4 doses)
Tdap (Tetanus, Diphtheria, Pertussis)/Td
Varicella (Chicken Pox)
The vaccines checked above should be given to the student named for whom I am authorized to make this request. I understand all doses indicated for each vaccine are needed to receive full protection. My signature here certifies and confirms my consent.

Please sign using your stylus, finger, or mouse. *
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