Child Immunization Consent Form
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1Child Immunization Consent Form
A. Personal information:
Surname
Given Name
Age
School
Grade
Classroom #
Date of Birth
9-Digit Manitoba Health Number (PHIN#)
Year
Month
Day
According to the Manitoba Routine Childhood Immunization schedule, it is time for the above person to receive the vaccine(s) checked off below:
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DTaP-IPV-Hib Diphtheria, acellular Pertussis, Tetanus,
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Pneu-C-13 Pneumococcal (conjugate 13 valent)
Polio, Haemophilus Influenzae B
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Pneu-P-23 Pneumococcal (polysaccharide 23 valent)
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DTaP-IPV
Diphtheria, acellular Pertussis, Tetanus, Polio
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Men-C-C
Meningococcal (conjugate)
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MMR
Measles, Mumps, Rubella
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MMRV
Measles, Mumps, Rubella, Varicella
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HBV
Hepatitis B (3 doses)
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HPV
Human Papillomavirus (3 doses)
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Tdap
Tetanus, diphtheria, acellular pertussis
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Other:
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Flu
Influenza
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Other:
A fact sheet is attached regarding benefits and risks of the vaccine(s). Please read carefully.
If you did not receive a fact sheet or if you have any questions, call your area public health office:_____________________________________
A public health nurse will provide this immunization on: Date: _____________________
B. Parent or legal decision-maker to complete:
1. Does your child have any allergies? No
Yes
(If yes, please describe):____________________________________________________
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2. Does your child have any health conditions that require regular visits to a doctor? No
I
Yes
I
(If yes, please describe):
_____________________________________________________________________________________________________________
3. Has your child ever had chickenpox? No
Yes
Year: ___________
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4. Has your child ever had chickenpox vaccine? No
I
Yes
I
Date: ____________________
5. Has your child ever had a reaction to a vaccine? No
I
Yes
I
(If yes, please describe):__________________________________________
6. Is your child pregnant? No
Yes
N/A
: ________________________________________________________________________
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I
I
Check one of the following four options:
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YES - I DO consent to the person named above
I
NO - I DO NOT consent to the person named above
receiving the vaccine(s) identified above.
receiving the vaccine(s) identified above.
OR
NO - My child already received the above named
I
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YES - I DO consent to the person named above
vaccine(s). Immunization received on:
receiving the vaccine(s) identified above except:
______________________________________________
_________________________________________
yy/mm/dd
(Please indicate which vaccine(s) you do not consent
from:__________________________________________
for the above named person to receive)
(Provide name of doctor/clinic/address)
Signature: ___________________________________ Relationship: _____________________________ Date: _____________________
Parent or legal decision-maker
year/month/day
Telephone number: (Home): ________________________ (Work): ________________________ (Cell): __________________________
Comments: _______________________________________________________________________________________________________
Notice: Information about vaccines that are given may be recorded in the Manitoba Immunization Monitoring System (MIMS) to support health care
by ensuring your child’s health care provider can find out what vaccines he/she has had or needs to have. Information collected in MIMS may also be
used by Manitoba Health to produce vaccination records or notify parents or health care providers when a child has missed a particular vaccine.
Manitoba Health may use the information to monitor how well different vaccines work in preventing disease. All information recorded in MIMS will
be protected in accordance with the protection of privacy provisions of The Personal Health Information Act.
IMPORTANT: Please return this form completed and signed to the school or public health nurse by: ________________________________
Section to be completed by the immunization provider:
Name of client:__________________________________________________
PHIN #: ________________________________________
Verbal Consent: The parent or legal decision-maker has been made aware of the benefits and the risks of the vaccine(s) offered to the above person
and consents for the child to be immunized on the following date: ________________________
The parent or legal decision-maker has agreed to complete the Child Immunization Consent Form provided to him/her and has agreed to forward
it to this immunizaton provider. Provider signature: ____________________________________________ Date: _____________________
Immunization Record: The vaccine(s) identified below were administered:
Vaccine
Number
Manufacturer
Lot #
Site
Route
Dose
Date
Provider signature
MIMS
Clerk’s
in series
y/m/d
entry
initials
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I
I
I
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TB Skin Test
Mantoux
Date planted
Lot #
Dose/Route/Site
Initial
Date read
mm of induration
Initial
Supplementary Information
Date
Notes (include immunization refusal)
Signature
MG-7707 (Revised June 2013)
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