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Immunization Consent Form - Cabot Public Schools

Immunization Consent Form - Cabot Public Schools 2025

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4.9 out of 5

49 votes

The document is an Immunization Consent Form from the Arkansas Department of Health for the influenza season. It collects personal and medical information from individuals receiving the flu vaccine, including medical history questions to assess eligibility. The form allows parents to indicate their preferred type of vaccine (flu shot or flu mist) and includes a release and assignment section for consent to vaccination and insurance processing. Additionally, it provides instructions regarding follow-up doses for children under 8 years old.

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Click ‘Get Form’ to open the Immunization Consent Form in the editor.
Begin by filling in the 'Person Receiving Vaccine' section. Enter the legal first name, middle initial, last name, and date of birth.
Complete the 'Medical History' section by answering the questions regarding previous vaccine reactions and health conditions. Select 'Yes' or 'No' for each question.
Indicate your preference for the type of flu vaccine (Flu Shot, Flu Mist, No Preference) if applicable.
In the 'Release and Assignment' section, read through the information provided. Sign and date where indicated to confirm your understanding and consent.
Fill out the 'Patient Information' section with details such as phone number, address, race, and insurance status.
Finally, review all entries for accuracy before saving or submitting your completed form.

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Versions	Form popularity	Fillable & printable
2018	4.9 Satisfied (49 Votes)
2012	4.4 Satisfied (235 Votes)

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