Consent For The Administration Of Vaccines/medications Form
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2Consent for the administration of vaccines/medications
First and Last Name: ___________________________________________________ Age: ______ Birth Date: _______________
Address: _____________________________________________________________ Telephone: ________________________
Doctor’s name and telephone: _____________________________________________________________________________
PHN (Personal Health Number): __________________________________________ Weight (if a minor): __________________
Vaccine/Medication Requested: __________________________________________________________________________
Note: Injections will not be provided to any children younger than 5 years of age. These individuals will be referred back to their
physicians. The parent or legal guardian must be present before an injection will be provided to any child age 5 to 18 years.
Name and relationship of person requesting injection for a minor (5 to 18 years):
______________________________________________________________________________________________________
Your health and safety is a priority. The following questions are to ensure that you do not have any contraindications and so we can
provide appropriate counselling. Please let us know if you have any concerns or questions.
Please answer the questions below:
Allergies:
• Have you ever had a serious reaction to any medication in the past?
Yes
No
o If yes, describe: ___________________________________________________________________________________
• Are you allergic to the following:
o Thimerosal, formaldehyde or any other preservative?
Yes
No
o Latex?
Yes
No
• Are you allergic to antibiotics (including; Neomycin, Kanamycin, Gentamycin, Streptomycin)?
Yes
No
o If yes, list: _______________________________________________________________________________________
• Do you have any food allergies, including to eggs or egg products?
Yes
No
o If yes, list: _______________________________________________________________________________________
• List any other known allergies: _________________________________________________________________________
Illness:
• Do you presently have a fever, infection, or any acute illness?
Yes
No
• Do you have any of the following:
o An active or unstable disorder of the nervous system?
Yes
No
o An autoimmune condition?
Yes
No
o A bleeding disorder?
Yes
No
o Have you had Guillain-Barré?
Yes
No
• List any current medical conditions: ____________________________________________________________________
Medication:
• Do you take any of the following medications:
o Immunosuppressant such as a Corticosteroid or Prednisone?
Yes
No
o Anticoagulant such as Warfarin or ASA?
Yes
No
o Beta-blocker?
Yes
No
• Have you received any blood products or vaccines in the past 30 days?
Yes
No
• List any medication that you currently take: ______________________________________________________________
Pregnancy Breastfeeding:
• If you are a woman, are you pregnant or think you may be?
Yes
No
• If you are a woman, are you currently breastfeeding?
Yes
No
Other:
• Are you a resident of Canada?
Yes
No
• If you are older than 50 years of age, have you had the shingles vaccine?
Yes
No
• Have you ever fainted after receiving an injection?
Yes
No
• List any other problems: _____________________________________________________________________________
Consent for vaccines/medications by injection
Rev August 2014
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