Immunization Consent Form

Do ot separate the 3 copies of this Consent Form. Please return all 3 copies to your school public health nurse. You will receive a copy after all vaccine(s) have been given.

Immunization Consent Form

Vaccines can prevent many communicable diseases. It is

recommended that you follow the immunization schedule

Public Health Services

that you can get from your local Public Health Services Office.

You/your child is now due for the following vaccine:

If you have any questions, please call your local Public Health

(Vaccine)

(# of Doses Required)

Services office (see above) or your family doctor before you

Please read and detach the Important Information sheet.

sign and return all 3 copies of this Consent Form to the

Public Health Nurse.

It will tell you about the vaccine, the disease(s) it prevents,

and the benefits, risks and side effects.

Print firmly with a ballpoint pen; you are making 3 copies.

STUDENT’S PERSONAL INFORMATION to be completed by parent/guardian or student

Student’s Full Name:

Parent/Guardian’s Name:

Address:

Postal Code:

Home Phone:

Work or Alternate Phone:

Doctor’s Name:

School Name:

Teacher’s Name and Room Number:

-

-

HEALTH CARD NUMBER:

Date of Birth:

Sex:

Year

Month

Day

M

F

Has this student ever had a serious reaction to a vaccine? Yes

No

If yes, explain

I have read the information sheet provided and understand the benefits, risks and side effects of the vaccine to be given.

Check ( ) one.

YES

I CONSENT to the vaccine now due.

NO

I DO NOT CONSENT

If already vaccinated with the vaccine listed above, provide: Date:

Signature:

Date:

(Parent/Guardian or Student)

For Public Health Use Only: to be completed by the Public Health Nurse

Vaccine Given:

Vaccine Trade Name:

1st Dose:

Site:

Route:

Lot #

Date:

Signature:

2nd Dose:

Site:

Route:

Lot #

Date:

Signature:

3rd Dose:

Site:

Route:

Lot #

Date:

Signature:

Copy distribution: GR

N – PHS; Y LLOW – Family Doctor; PINK – Parent/Guardian or Student

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