Lake County Health Department Immunization Form

Vaccine Consent Form
Forms are due a week before clinic event.

Send to thornca@lakecountyin.org / 219-755-3658 ext. 331
VaxCare/VFC
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender
Race
Primary Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian:
Relationship:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Insurance Information
Relationship to Insured:

DependentSelf
Select the vaccine(s) for the patient to receive
Vaccine Health Screening (choose Yes or No)
Please answer all questions about the patient who will be receiving the vaccine(s). Answers will determine whether the patient can be vaccinated at this time.
1. Does the patient have any allergies to medication, foods, or any vaccines?

YesNo
If yes, please explain:
2. Has the patient had a serious reaction to a vaccine in the past?

YesNo
3. Has the patient had a health problem with asthma, lung disease, heart disease, kidney disease, metabolic disease (i.e. diabetes), or a blood disorder?

YesNo
If yes, please explain:
4. Has the patient had a seizure, brain, or other nervous system problem, including Guillain-Barre Syndrome?

YesNo
5. Does the patient have cancer, leukemia, AIDS, active tuberculosis, or any other immune system problem?

YesNo
6. Has the patient taken cortisone, prednisone, other steroids or anticancer drugs or had radiation treatments in the past three (3) months?

YesNo
7. Has the patient received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug in the past year?

YesNo
8. Is the patient pregnant or is there a chance she could become pregnant during the next month? If yes, student should not receive MMR, HPV, or Varicella vaccines.

YesNo
9. Has the patient received vaccines in the past four (4) weeks?

YesNo
If yes, please list vaccines:
Immunization Clinic Consent Form
I give permission to the Lake County Health Department, the Indiana State Department of Health, and/or their designee to vaccinate the patient named in this form.
Signature:*
Signature of Parent/Guardian:
Date:*

MonthDayYear
Date

Vaccine Consent Form

Vaccine Health Screening (choose Yes or No)

Immunization Clinic Consent Form