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Vaccine Consent Form Template

Streamline your immunization process with ease

Collecting consent for immunizations can be challenging, especially when accuracy and compliance are essential. Our Vaccine Consent Form Template is designed for healthcare providers and clinics who want to ensure patients understand and authorize their vaccinations. This easy-to-use template offers customizable fields, WCAG-aligned labels for improved accessibility, and a convenient layout that simplifies the consent process, fosters trust, and maintains confidentiality. Explore the benefits of using this streamlined form today.

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Are you the patient?
Yes, I am the patient
No, I am signing on behalf of a minor or another person
Patient full name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Home address (street, city, state, ZIP)
Email
Mobile phone
Parent/guardian full name (if applicable)
Relationship to patient (if applicable)
Parent/guardian
Spouse/partner
Caregiver
Power of attorney
Not applicable
Other
Please Specify:
Vaccine requested/consented for today
Please Specify:
If Other, specify vaccine name
Planned vaccination date
Dose number
First dose
Second dose
Booster/additional dose
Unknown/unsure
Are you feeling sick today, including fever?
Yes
No
Not sure
Do you have any allergies to medications, foods, latex, or vaccine components?
Yes
No
Not sure
Have you ever had a serious allergic reaction (e.g., anaphylaxis) to a vaccine or injectable therapy?
Yes
No
Not sure
Do you have a bleeding disorder or take blood thinners?
Yes
No
Not sure
Are you immunocompromised or taking medications that suppress the immune system?
Yes
No
Not sure
Are you currently pregnant?
Yes
No
Not applicable
Are you currently breastfeeding?
Yes
No
Not applicable
Have you received any vaccines in the past 14 days?
Yes
No
Not sure
Any other medical conditions the vaccinator should know about?
Have you ever fainted or had a severe reaction after receiving an injection?
Yes
No
Not sure
Emergency contact full name
Emergency contact relationship
Parent/guardian
Spouse/partner
Relative
Friend
Caregiver
Other
Please Specify:
Emergency contact phone
Insurance provider (optional)
Member ID (optional)
Group number (optional)
Will insurance be used for this vaccination?
Yes
No
Not sure
Not applicable
I have received and read the vaccine information sheet for the vaccine selected above.
Yes
No
I understand the benefits and risks of vaccination and had the opportunity to ask questions.
Yes
No
I authorize sharing my immunization record with registries and my healthcare providers as permitted by law.
Yes
No
Signature of patient or legal representative (type full name)
Date of signature
I consent to receive the vaccine today for the patient named above.
Yes, I consent
No, I do not consent
Vaccine administered
Please Specify:
Manufacturer
Lot number
Expiration date
Dose number given
First dose
Second dose
Booster/additional dose
Unknown/unsure
Administration site
Left deltoid
Right deltoid
Left thigh
Right thigh
Other
Please Specify:
Route
Intramuscular (IM)
Subcutaneous (SC)
Intradermal (ID)
Other
Please Specify:
Vaccination date
Administrator name and title
Observation completed without incident
Yes
No
Not applicable
Provider notes
Adverse event noted
Yes
No
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Paper art illustration of a vaccine consent form template for FormCreatorAI article

When to use this form

Use this form before giving any routine, travel, or workplace vaccine. Clinics, pharmacies, schools, and mobile events use it to confirm identity, screen for allergies or past reactions, explain risks and benefits, and capture a legal signature. For minors, have a parent or guardian sign; you may pair it with a Child medical consent form. Pediatric offices often attach prior records with a Pediatrics medical release form. For off-site or after-hours clinics, keep an Emergency permission form in case immediate treatment is needed. The result: faster check-in, clear consent, and accurate records for your EHR and state registry. You can adapt it for single-dose shots or multi-dose schedules and collect insurance details as needed.

Must Ask Vaccine Consent Questions

  1. Which vaccine(s) are you consenting to receive today?

    Naming the product, dose number, and body site sets clear scope and prevents administration errors. It also ensures correct documentation and billing.

  2. Have you reviewed the vaccine information and had your questions answered?

    This confirms informed consent and that you understand benefits and risks. It improves satisfaction and supports compliance requirements.

  3. Have you ever had a serious reaction or allergy to a vaccine or its ingredients?

    This flags risks such as anaphylaxis or allergies to latex, eggs, or yeast. With this info, staff can defer, choose an alternative, or observe you longer.

  4. Are you currently ill, pregnant, or immunocompromised?

    These conditions can change timing or type of vaccine. Screening helps schedule safely or refer to a clinician when needed.

  5. Do you authorize emergency care if you have a severe reaction during your visit?

    Explicit permission speeds treatment if it becomes necessary and clarifies who may decide. If your organization needs broader consent, see the Medical authorization form.

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