Immunizations Consent Form

By getting your child vaccinated, you can protect him/her and also avoid spreading preventable diseases to other people in your community.

Vaccinating on time during childhood is the best way parents can protect their child because it helps provide immunity from 16 potentially life-threatening diseases. Vaccine-preventable diseases can be very serious, may require hospitalization, or even be deadly in infants and young children.

You should only complete this form AFTER contacting one of Ritchie Regional Health Center's respective sites to schedule an appointment and confirm the necessary vaccine(s).

By filling out this form and electronically signing/initialing it, you:

- Are the legal parent or guardian of the patient named below

- Acknowledge and understand the risks and benefits of the vaccine(s) being administered

- Give Ritchie Regional Health Center's clinical staff permission to administer discussed vaccine(s)

For additional information about the vaccines, click or tap HERE.

Patient Name:*

Birth Date:*

Date

Gender (as appears on birth certificate):

MaleFemale

Address:*

Phone:*

Parent/Guardian:*

Physician:

Please specify which Ritchie Regional Health Center Campus you are requesting an appointment at:

Does your child attend one of the following schools: Ritchie County Middle School; Ritchie County High School; Smithville Elementary School; Doddridge County Elementary School; Doddridge County Middle School; Doddridge County High School; Parkersburg South High School; Jefferson Elementary School; St. Marys High School?*

YesNo

IF yes, do we -- Ritchie Regional Health Center -- have permission to pull your child directly from class during school hours for their appointment?*

YesNo

Please INITIAL the appropriate vaccine(s) you give us permission to administer to your child. If you aren't sure of which vaccine(s) to consent for, please contact us before submitting:

1. Hepatitis B (Hep B)

2. Diphtheria, Tetanus, Pertussis (DTaP/TdaP)

3. Haemophilus influenza type b (Hib)

4. Polio (IPV)

5. Rotavirus

6. Measles, Mumps, Rubella (MMR)

7. Varcella

8. Hepatitis A (Hep A)

9. Meningococcal

10. Human papillomavirus (HPV)

11. Meningococcal B

12. Influenza (Flu)

13. COVID

14. PPD

15. Other

Date

Parent/Guardian Signature:*

Parent/Guardian Initials:*