Vaccine Consent Form in Absent of Parent or Caregiver

I consent to the administration of the following vaccine(s) to be given to my child:

The Vaccine Information Statement (VIS) for the above vaccine(s) has been made available to me and may be reviewed at VIS

I have read the contraindications and have discussed any concerns with my healthcare provider and I give permission and written consent to Westside Pediatrics PC to administer the above vaccine(s).
Parent/Guardian Signature*

Clear
Date*

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Date
Should be Empty:

Vaccine Consent Form in Absence of Parent/Guardian