Consent Form For When Somebody Else Brings Your Child For Immunisation

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CONSENT FORM FOR WHEN SOMEBODY ELSE
BRINGS YOUR CHILD FOR IMMUNISATION
Consent for Immunisation
Re: _______________________________
, Date of Birth: ___/___/______
(child’s name)
I, __________________________________
, parent of the above child, confirm that,
(parent’s name)
having received information from NHS Worcestershire or my health visitor, I have asked
______________________________
to bring the above named
( relative, childminder or friend’s name)
child for vaccination, and that I have given my consent for the following vaccine(s) to be given:
________________________
________________________
________________________
Signed: _______________________
Date: ___/___/______
Department of Health policy is that:
1
“The person with parental responsibility
does not necessarily need to be present at the time the
immunisation is given. Although a person may not abdicate or transfer parental responsibility, they may
arrange for some or all of it to be met by one or more persons acting on their behalf (Section 2(9) of the
Children’s Act 1989). There is no requirement for such arrangements to be made in writing. Children may
be brought for immunisation by a person without parental responsibility, for example, a grandparent or
childminder. Where a child is brought for immunisation by some one who does not have parental
responsibility the health professional would need to be satisfied that:
□ the person with parental responsibility has consented in advance to the immunisation (i.e. they
received all the relevant information in advance and arranged for the other person to bring the child to
the appointment) or
□ the person with parental responsibility has arranged for this other person to provide the necessary
consent (i.e. they asked the other person to take the child to the appointment, to consider any further
information given by the health professional, and then to agree to immunisation if appropriate).”
(Reference: Immunisation against infectious disease - 'The Green Book').
In practice, this form will help ensure that the conditions in this policy are met.

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