Vaccination consent

Safety screening and signed consent for vaccination drives and clinics.

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Vaccination consent

Full name of the person receiving the vaccine

Nombre

Apellido

Date of birth

Vaccine to receive

Safety screening

Have you ever had a severe allergic reaction to a vaccine or any of its components?

Yes No

Describe the reaction and the vaccine

Are you feeling sick or feverish today?

Yes No

Are you pregnant or could you be?

Yes No Not applicable

I declare the information above is truthful. I was informed about the vaccine's benefits and possible side effects, had the chance to ask questions, and voluntarily agree to receive it.

Signature of patient or guardian

Sign here

Date

Vaccination consent

Vaccination consent

Safety screening

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