Immunization or Injection Consent Form Logo
  • Immunization or Injection Consent Form

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  • Please explain:

  • Please explain:

  • Please explain:

  • I have been given a copy and have read, or had explained to me, the information contained in the Vaccine Information Statement about the disease and vaccine. I understand the benefits and risks of the vaccine and request that the vaccine be given to me or the person for whom I am authorized to make this request. I agree that this information may be shared with schools, daycare centers, healthcare providers and others when medically necessary. I have been given a copy of the Brent's Pharmacy & Diabetes Care Notice of Privacy Practices and have had a chance to ask questions about how my public health information will be used. I understand that it is my responsibility to know what my insurance plan covers and agree to pay the portion not covered by my insurance. I understand that if Brent's Pharmacy & Diabetes Care does not have a contract with my insurance company, or my insurance company denies payment, I am responsible for all charges incurred.

  • I request that the specified vaccine/injection be given to me or the person named above, for whom I am the parent or legal guardian.

  • Vaccine/Injection

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