PRINT A COPY OF THIS AND SEE WHAT HAPPENS

COPY AND PASTE INTO MS WORD

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.
Responsible 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(s), drugs 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 needs and expenses of the patient involved.
Date: _____________________________
Signature of responsible physician: _______________________________________Signature of responsible person administering vaccination/medication/drug: __________________________________________Occupational Title: _________
Signature of Witness: Parent or other: ____________________________
PRESENT THIS TO YOUR DOCTOR WHEN VACCINATING YOUR LOVE ONES! HE’LL NEVER SIGN IT