Vdh client id# last name first name middle name birth date. Form reviewed by date adapted with appreciation from the immunization action coalition (iac) screening checklists. Last name first name middle name (optional) mother’s maiden name (optional) date of birth (mm/dd/yyyy) gender address no address available insurance information
Information About You (Please Print) Last Name
Before you proceed, please read the following: Last name first name middle initial. (b) the legal guardian of the patient and confirm that the patient is at least 12 years of age (for pfizer vaccine consent only);
Patient Information (Staff Only) Appointment Id:
Information about patient (please print) I understand there will be no cost to me for this vaccine. Information about minor child to receive vaccine (please print) minor’s name (last) (first) (m.i.) minor’s date of birth (mm/dd/year):
I Understand That If My Vaccine Requires Two
I consent to receiving the vaccine, including all recommended doses in the series. I understand that if this vaccine requires two doses, two doses of this vaccine will need to be administered (given) in order for it to be effective. Date of birth are you a minor less than 18 yrs old sex yes.