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Consent for Administration of Vaccination


Dear (Physician’s Name):

If you will be administering a vaccination to me, or my child, today, I will need for you to complete the following consent form. Thank you.


Physician Statement
I, (Physician Name) _________________ do hereby state that I have advised my patient,
(patient or child’s name) _________________and/or parent of my patient, (parent’s name) _______ that in my professional opinion this patient/child should be given the vaccination, drug or other (name of vaccination/drug/other) ______________.

Manufacturer’s name ___________Serial number ________Batch Number ____________.

I have on this (day) __________ (month) ______________ (year) ______________administered this vaccination/medication/drug AFTER advising the above named patient/parent of minor patient that there is little or no risk involved with this vaccination/medication/drug therapy or treatment.

I hereby do agree that should this patient/child at anytime suffer or develop any permanent condition deleterious or injurious to his/her health as a result of this treatment, I will pay for any and all costs involved related to the care and treatment necessary for this patient/child for the rest of his/her natural life.

I further agree that if my earnings are insufficient to meet these costs, I will sell my home, my business and all material possessions and put those proceeds towards meeting the expenses of the patient involved.


Date: ____________

Signature of responsible physician:

Signature of responsible person administering vaccination/medication/drug:

Occupational Title:

Witness: Parent or other: