Doctor's Consent for Vaccination Responsibility

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: _____________________________