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Click ‘Get Form’ to open the IMMUNIZATION CONSENT FORM in the editor.
Begin by filling in your personal information. Enter your First Name, Middle Initial, Last Name, Address, State, City, Zip Code, Birthdate, Phone Number, Age, and Sex (M/F/Undesignated).
In the Precautions and Contraindications section, carefully read each question and check 'YES' or 'NO' as applicable. If you answer 'YES' to any question, it is advised to contact your physician before proceeding.
Review the INFLUENZA VACCINE ADVERSE REACTIONS section for important information regarding potential side effects.
The area below is designated for the nurse's completion. Ensure that this section is filled out during your visit.
Complete the PAYMENT INFORMATION section by entering amounts paid for each vaccine type as applicable.
Finally, sign and date the consent at the bottom of the form. Make sure to print a copy for your records and provide one to your healthcare provider.

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Is it illegal to not vaccinate your child in New York?

The New York State Immunization Information System (NYSIIS) is an electronic registry that maintains immunization records for New York State children and adults.

Can you be vaccinated without your consent?

All vaccines administered should be fully documented in the patients permanent medical record. Health care providers who administer vaccines that are covered by the National Vaccine Injury Compensation Program are required by law to ensure the permanent medical record of the recipient indicates: Date of administration.

Is consent required for vaccines?

Should students or student health offices complete the form? Students should complete the AAMC Standardized Immunization Form in conjunction with either the student health office at their medical school or with their primary care provider.

Who can fill out my immunization form?

Children attending day care and pre-K through 12thgrade in New York State must receive all required doses of vaccines on the recommended schedule in order to attend or remain in school. This is true unless they have a valid medical exemption to immunization. This includes all public, private, and religious schools.

Do you need informed consent for vaccines?

There is no Federal requirement for informed consent relating to immunization. For state and local regulations, check with your local or state health department.