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IMMUNIZATION CONSENT AND HISTORY - Missouri Department of ... - health mo 2025

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The document is an immunization consent and history form from the Missouri Department of Health and Senior Services. It collects personal information about the patient, including demographics and vaccination history, while obtaining consent for various vaccines. The form outlines eligibility statuses for different health insurance categories and includes sections for recording vaccine details such as type, administration date, site, manufacturer, and signatures of both the vaccinator and the consenting party.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's last name, first name, middle initial, and date of birth in the designated fields. Ensure accuracy for proper identification.
Fill in the sex, street address, city, state, and zip code. This information is crucial for demographic records.
Select applicable race and ethnicity options from the provided checkboxes to ensure comprehensive data collection.
Input the parent or guardian's full name if applicable. This section is essential for consent verification.
Review the vaccine information statement and confirm understanding by signing where indicated. This step ensures informed consent.
Complete each vaccine section by circling the type given, entering visit dates, injection sites, manufacturer details, and obtaining necessary signatures.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (27 Votes)
2011	4.4 Satisfied (60 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is full consent for immunisation?

For consent to immunisation to the valid, it must be given freely, voluntarily and without coercion by an appropriately informed person who has the mental capacity to consent to the administration of the vaccines in question.

Is it a Hipaa violation to ask about vaccinations?

Disclosure of an Individuals Vaccine Status by a Healthcare Provider. Healthcare providers can ask if a patient has been vaccinated as asking the question in no way violates HIPAA.

Why is it important to obtain the parents informed consent before administering an immunization to a child?

Informed consent ensures that patients understand the risks, benefits, alternatives, and potential consequences of medical interventions, allowing them to weigh their options and participate actively in their treatment plans.

Do vaccines require informed consent?

The University of Missouri requires all new students to submit an MU Immunization/TB Screening Requirements form and verification of TB screening before registering for classes. The completed form must be submitted directly to the MU Student Health Center.

Where do I send my immunization records in Mizzou?

Vaccination records (sometimes called immunization records) provide a history of all the vaccines you or your child received. This record may be required for certain jobs, travel abroad, or school registration.

Key Facts about the Missouri Immunization Consent and History Form

Comprehensive Vaccine Information

Eligibility Status Options

Consent Requirement

Vaccine Information Statements (VIS)

Multiple Visit Tracking

Demographic Information Collection

Vaccinator Signature Requirement

Comprehensive Vaccine Information

The form includes detailed sections for various vaccines, including Hepatitis B, DTaP, Hib, Polio, Pneumococcal, Rotavirus, Hepatitis A, MMR, HPV, Meningococcal, Tdap, and Influenza.

Eligibility Status Options

It provides multiple eligibility status options for patients such as Medicaid, no health insurance, American Indian/Alaska Native status, and underinsured categories.

Consent Requirement

The form requires a signature from the patient or parent/guardian to indicate consent for vaccination after being informed of the benefits and risks.

Vaccine Information Statements (VIS)

Patients must acknowledge receipt of the Vaccine Information Statements (VIS) for the vaccines indicated on the form.

Multiple Visit Tracking

The form allows tracking of multiple vaccination visits with spaces for dates and signatures for each vaccine administered.

Demographic Information Collection

It collects essential demographic information such as name, date of birth, sex, race, ethnicity, address, and phone number.

Vaccinator Signature Requirement

Each vaccine entry requires a signature from the vaccinator to confirm administration and compliance with health regulations.

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