IMMUNIZATION CONSENT FORM

IMMUNIZATION CONSENT FORM
Patient's Name

First NameLast Name
Patient's DOB

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Mother's Maiden Name
Parent's / Guardian's Names
I have read or had explained to me the information in the vaccine
information sheet about the disease(s) and the vaccine(s) to prevent them.
I have had a chance to ask questions that were answered to my
satisfaction. I believe I understand the benefits and risks of the vaccine(s)
and ask that the vaccine(s) indicated be given to me or the person named
above for whom I am authorized to make this request.
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Relationship to patient
Information Reminder Information Systems (IRIS) is a voluntary program. I
understand that the child listed above will have vaccines automatically
recorded in Idaho’s immunization registry (IRIS) unless I choose to “opt-out”. The
“opt-out” forms are available at www.immunizeidaho.com
Type a label Initial
Should be Empty: