Back-to-School Vaccine Consent

Back-to-School Vaccine Consent

Service provided by the Putnam County Health Department.
Child Information
Name

First NameLast Name
DOB

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address 2

CityState

Zip Code
Insurance
Please select one of the below.
Please attach a photo of the front and back of insurance card.

Cancelof
Health History

Vaccine Screening

Rows	Yes	No	If Yes, Please Explain
Is your child sick today?
Does your child have any food or medication allergies?
Does your child have a history of fainting or seizures?
Does your child have a serious medical condition?
Has your child ever been diagnosed with Guillain-Barre Syndrome?
Is your child pregnant?
Is your child currently on antibiotics or antiviral medications (example: Amoxicillin, Tamiflu, Bactrim, etc.)

Do you have any questions/concerns regarding vaccines that you would like for a nurse to contact you about?
Vaccine Selection

To be administered on Wednesday, March 20, 2024
I give permission for my child to have the following vaccines:
Vaccine Information Statements

Tdap - Click here to read the VIS.
HPV - Click here to read the VIS.
Meningococcal B - Click here to read the VIS.
Meningococcal - Click here to read the VIS.
HIPAA Compliance
Click the link below to read the full disclosure of HIPAA.
Acknowledgment of HIPAA Compliance
Consent
Consent For Immunization

Yes, please vaccinate my child with the vaccines I have indicated above. I have read or been provided with the opportunity to read the associated Vaccine Information Statement for the vaccine indicated above. I have had the opportunity to ask questions. I understand the benefits and risks of the vaccine requested and ask that the vaccine for which I have signed below, be given to the person indicated above. I am authorized by RSMo 431.058 to make this request.
Parent/Guardian Signature
Should be Empty:

Child Information