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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.

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, drug 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 expenses of the patient involved.

Date: _____________________________

Signature of responsible physician: ________________________________

Signature of responsible person administering vaccination/medication/drug: ______________________

Occupational Title: ___________________________

Witness: Parent or other: _____________________________