Request For Vaccination- Consent Form
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1IMU Southwest Clinic
REQUEST FOR VACCINATION(S) - CONSENT FORM
The IMU Southwest Clinic will keep this record in you or your child's medical file. It records what vaccine(s) and/or test(s) were
given, the date when the vaccine(s) and/or test(s) were given, the name of the company that made the vaccine(s) and/or test(s), the lot
number of the vaccine(s) and/or test(s), and the address where the vaccine(s) and/or test(s) were administered. By signing the form
below, you hereby freely and voluntarily give your permission and are requesting that the vaccine(s) and/or test(s) indicated by your
signature(s) below be given to you or the person named below for whom you are authorized to make this request. The IMU Southwest
Clinic will give you a "Vaccine Information Sheet" on each vaccine, or a "Subject Information" pamphlet on each test, as stated by law,
for you to read BEFORE you receive your shots and/or test(s). Your signature below indicates that you have read, or have had the
information explained to you and that you understand the benefits and risks of each vaccine administered. You hereby release and
agree to hold harmless The IMU Southwest Clinic, its Officers, and Employees for any and all liability, of any kind or nature whatsoever,
which might arise out of or result from any vaccine(s) and/or test(s) administered to you or your child.
PLEASE PRINT ALL ENTRIES CLEARLY
Last Name ___________________________ First Name _________________ Middle Initial ____Date of Birth_________
Street Address ____________________________________________________________
Age _________
City ________________________ State ________________ Zip Code ______________Telephone ________________
E-MAIL ______________________________________________________________________
ONLY If Person receiving vaccine/ testing is under 18, PRINT parent's/guardians name in this space:
Mother's Maiden Name _______________________ Father's Name ______________________
Or Legal Guardian _____________________________________________
RACE/SEX: Please check the box that applies to the person being immunized/tested:
□
□
□
□
□
□
Asian Male
Black Male
Hispanic Male
Oriental Male
Other Male
White Male
O
O
O
O
O
O
Asian Female
Black Female
Hispanic Female
Oriental Female
Other Female
White Female
ALLERGIES TO MEDS OR FOODS _____________________________Nurse’s Signature & Title ____________________
Signature (s):
Vaccine/Test
1
2
Route
Manuf.Co.
Lot#
Site
VIS/Info Form
01
DT
/ /
/ /
Sanofi P
07/30/01
02
Dtap
/ /
/ /
AV/GSK
05/17/07
03
Hepatitis A
/ /
/ /
M/GSK
10/25/11
04
Hepatitis B
/ /
/ /
M/GSK
02/02/12
05
Hib
/ /
/ /
Aventis
12/16/98
06
Influenza
/ /
/ /
07/26/11
07
IPV (polio)
/ /
/ /
Sanofi P
01/01/00
08
Jap. Encep.
/ /
/ /
Novartis
12/07/11
09
Meningitis
/ /
/ /
SP/Nov
10/14/11
10
MMR
/ /
/ /
Merck
03/13/08
11
Pneumonia
/ /
/ /
Merck
07/29/97
12
PCV7
/ /
/ /
Wyeth
09/30/02
13
Rabies
/ /
/ /
Novartis
10/06/09
SP/GSK/MP
11/18/08
14
Td/Tdap
/ /
/ /
15
Typhoid
/ /
/ /
SP/Bern
05/19/04
02/02/12/ 05/03/11
16
HPV
/ /
/ /
Merck/GSK
17
Varicella
/ /
/ /
Merck
03/13/08
18
Yellow Fever
/ /
/ /
Aventis
11/09/04
19
Other:
/ /
/ /
20
HIV Rapid Test
/ /
/ /
OraSure
03/2005
21
PPD Skin Test
Given
/ /
Read
Mm
Sanofi P
N/A
Clinic/Site Location: 3727 Greenbriar Dr. #403. Stafford, TX 77477
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