Vaccine Authorization Form

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, hereby authorize the
Print Name of Parent or Guardian
office of Niranjana Rajan, M.D, P.A. to administer immunizations to
my child according to the schedule set forth by the American Academy
of Pediatrics. The office of Niranjana Rajan, M.D., P.A. will provide
information regarding each immunization, including risks and benefits.
The Parent/Guardian will have the opportunity to ask questions and
discuss the administration of vaccines to my child. If there is an
immunization which the Parent/Guardian does not wish their child to
receive then a Refusal To Vaccinate Form will be signed for that
particular vaccine.
Date of Birth: ______________________________________________
Signature of Parent/Guardian:__________________________________


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