A vaccine consent form screens a person before a vaccine, records their consent or their choice to decline, and logs each dose given: the product, lot number, site, and who gave it. Copy the free form, see a pharmacy flu and pneumococcal example and a nurse’s flu vaccine declination, and check what goes in each part.
Blank vaccine consent form template
FreeVACCINE CONSENT FORM Screening, consent or declination, and administration record THE PERSON Name: [Full name] Date of birth: [Date] Phone: [Mobile number] Record number: [Clinic, pharmacy, or employee number] Usual clinician: [Name and practice, or none] Consent given by: [The person, or a parent, guardian, or substitute decision-maker, with their name and relationship] Language: [Preferred language, and the interpreter used, or none] Vaccines offered today: [Each vaccine, and the dose number in its series] PART 1: SCREENING BEFORE VACCINATION Answer yes, no, or don't know for each. A yes doesn't always mean no vaccine today; the vaccinator will talk it through with you. Feeling unwell today: [Yes or no, with any fever or other symptoms] Severe allergy: [Yes or no: to a vaccine, a vaccine ingredient, latex, a medicine, or anything else, with the reaction] Reaction to a past vaccine: [Yes or no: which vaccine, what happened, and when] Guillain-Barré syndrome: [Yes or no, and whether it followed a vaccine] Pregnant or could be pregnant: [Yes, no, or not applicable, with the weeks if pregnant] Weakened immune system: [Yes or no: cancer treatment, high-dose steroids, a transplant, HIV, a biologic medicine, or another cause] Blood products or antibody treatment in the past year: [Yes or no: what, and when] Vaccines in the past 4 weeks: [Yes or no: which, and the date] Bleeding disorder or blood thinner: [Yes or no: the condition or the medicine] Fainting: [Yes or no: fainted or felt faint with a needle before] Screened by: [Name, role, date, and time] Outcome: [Vaccinate today; wait until a date, and why; or don't give, and why] PART 2: CONSENT Information given: [The vaccine information sheet your jurisdiction requires for each vaccine, its version date, and how it was given: paper, screen, or link] Discussed: [Common side effects, rare serious reactions, the risk of the disease without the vaccine, and what to do afterward] Questions: [Questions asked and the answers given, or none] Statement: I have read, or had explained to me, the information about each vaccine listed above. I had the chance to ask questions, and they were answered. I understand the benefits and risks, and I consent to receive these vaccines today. I can change my mind at any time before a vaccine is given. Signed: [Signature of the person or their substitute decision-maker, printed name, relationship, and date] Verbal consent: [If consent was given aloud instead: who heard it, and the time, or not applicable] PART 3: DECLINATION Fill in only if you choose not to have a vaccine offered today. Vaccine declined: [Vaccine, and the season or dose] Statement: I was offered the vaccine above. I was told about the disease it protects against, and about the vaccine's benefits and risks. I understand that without it I am more likely to catch the disease and have complications, and that I could pass it to others, including people at high risk. I can change my mind at any time and have the vaccine. Reason, optional: [The reason the person chooses to give, or prefers not to say] Medical contraindication: [None; or the contraindication and the clinician who confirmed it, recorded as a medical exemption instead] Workplace policy: [For staff: the employer's rule for unvaccinated staff, such as masking during flu season, and that it was explained; or not applicable] Signed: [Signature, printed name, and date] Witness: [Staff name, role, and date] Offered again: [Date or occasion, and how to get the vaccine later] PART 4: ADMINISTRATION RECORD Copy this block for each vaccine given. Vaccine: [Product, type, and dose number in the series] Manufacturer: [Manufacturer] Lot number: [Copied from the vial, syringe, or box] Expiry date: [Date] Dose: [Volume in mL] Route: [Intramuscular, subcutaneous, intranasal, or oral] Site: [Left or right deltoid, left or right thigh, or other] Needle: [Length and gauge] Date and time given: [Date and time] Given by: [Name, credentials, and the clinic or pharmacy address] Information sheet: [Version date of the sheet given for this vaccine] AFTER THE VACCINE Observation: [Start and end times, 15 minutes or 30 when there is a concern about allergy, and who observed] Reaction: [None; or what happened, the time, the treatment given, and who was told] Reaction reported: [To the vaccine safety reporting system where you practice, or not needed] After-care: [Expected side effects, when to get help, and how to reach the clinic] Next dose due: [Vaccine and date, or series complete] Record shared: [Immunization registry, the person's usual clinician, and a copy or wallet card for the person]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
A 68-year-old at a community pharmacy; one vaccine in each arm, 15-minute observation
Gerald Mensah, born March 14, 1958, age 68. Pharmacy profile 40217. Usual clinician: Dr. Laura Chen, Riverside Family Health. Consenting for himself; English, no interpreter. Vaccines offered: adjuvanted influenza vaccine for the 2026–2027 season, one of the flu vaccines preferred at 65 and older; and a 20-valent pneumococcal conjugate vaccine, one dose. He has never had a pneumococcal vaccine.
Feeling unwell today: no; no fever. Severe allergy: no; penicillin gives him a rash, which doesn’t affect these vaccines. Reaction to a past vaccine: a sore arm after past flu shots, nothing more. Guillain-Barré syndrome: no. Pregnancy: not applicable. Weakened immune system: no; type 2 diabetes on metformin. Blood products in the past year: no. Vaccines in the past 4 weeks: none; shingles series finished in 2024. Bleeding disorder or blood thinner: yes, apixaban 5 mg twice a day for atrial fibrillation; keep taking it. Fainting: no. Outcome: vaccinate today, with a fine needle and firm pressure for 2 minutes after each injection, without rubbing. Screened by Priya Raman, pharmacist, November 9, 2026, 10:30 a.m.
Gave him the vaccine information sheet our jurisdiction requires for each vaccine, on paper, and went through them together. Discussed: a sore, red, or swollen arm, tiredness, headache, and a mild fever for a day or two are common; serious allergic reactions are rare, and staff are ready to treat one. He asked whether the flu vaccine can give him the flu; explained that it can’t, because it has no live virus. He asked whether he’ll need more pneumonia shots; explained that this one dose completes his pneumococcal vaccination. Signed by Gerald Mensah at 10:36 a.m.
Influenza vaccine, adjuvanted, 2026–2027 formula. Manufacturer: Seqirus. Lot AQ2614A, expiry June 30, 2027. 0.5 mL intramuscular, left deltoid, 25 mm 25-gauge needle, 10:41 a.m. Pneumococcal conjugate vaccine, 20-valent. Manufacturer: Pfizer. Lot LJ8172, expiry March 31, 2028. 0.5 mL intramuscular, right deltoid, 25 mm 25-gauge needle, 10:43 a.m. Firm pressure for 2 minutes at each site. Information sheet version dates recorded for both. Given by Priya Raman, pharmacist, Elm Street Pharmacy, 212 Elm Street.
Observed seated in the pharmacy for 15 minutes, 10:43 to 10:58 a.m., by Priya Raman. No reaction; no bleeding or swelling at either site at 10:58. After-care: a sore arm and tiredness may last a day or two; acetaminophen if needed; call 911 for trouble breathing or swelling of the face or throat; call the pharmacy with anything else. Next due: influenza vaccine in fall 2027. Pneumococcal: series complete. Record shared: entered in the immunization registry, sent to Dr. Chen, and a wallet card for Mr. Mensah. He left at 11:00 a.m.
Hospital occupational health, during the workplace flu campaign; no vaccine given
Jenna Kowalski, born July 22, 1993, age 33. Registered nurse, medical oncology unit, employee number 58214. Offered: inactivated influenza vaccine for the 2026–2027 season, free from occupational health or the unit’s peer vaccinator during the hospital campaign, October 15 to December 15.
Feeling unwell today: no. Severe allergy: no; no drug allergies. Reaction to a past vaccine: a sore arm and aching for 2 days after last year’s flu vaccine; no hives, swelling, or trouble breathing. Guillain-Barré syndrome: no. Pregnant: no. Weakened immune system: no. Bleeding disorder or blood thinner: no. Fainting: no. Outcome: no contraindication found; she could be vaccinated today. Screened by Mark Delaney, occupational health nurse, November 4, 2026, 2:00 p.m.
She said she’s healthy, rarely gets sick, and doesn’t want 2 more days of aching during a run of night shifts. Explained: aches after the vaccine are common and pass in a day or two, and she could have it before her days off. People can spread flu from a day before their symptoms start, and some have mild symptoms or none, so a nurse can pass it to patients without knowing she has it. Many of her patients are on chemotherapy, and flu can be severe or fatal for them. The vaccine lowers her chance of catching flu and passing it on, and it can’t give her flu. She understood and still declined.
Vaccine declined: influenza vaccine, 2026–2027 season. Reason, optional: side effects during night shifts. Medical contraindication: none, so this is recorded as a declination, not a medical exemption. Workplace policy: under the hospital’s influenza policy, staff who aren’t vaccinated wear a surgical mask in patient care areas from the day the hospital declares flu season until it declares it over. Explained, and she agreed to follow it. She can change her mind at any time: the vaccine stays free at occupational health, weekdays 7 a.m. to 3 p.m., and from the unit’s peer vaccinator. Signed by Jenna Kowalski, witnessed by Mark Delaney, November 4, 2026, 2:15 p.m.
Declination entered in her occupational health record; her reason stays there. Her manager is told only that she is on the masking list. No administration record, since no vaccine was given. Offered again on November 25, when the peer vaccinator visits her unit, and at next fall’s campaign. Decision: declined for this season; masks in patient care areas while flu season is declared.
Who is being vaccinated, who is consenting, and which vaccines are on offer today.
Avoid: “Flu shot” and nothing else. Name the type, such as adjuvanted or high-dose, so the form matches the vial you draw up.
Short yes-or-no questions that catch a reason to wait, to choose a different vaccine, or to take an extra step before the needle.
Avoid: Treating every yes as a no. Most answers change how or when you vaccinate, not whether. Write what each yes led to.
The person’s agreement, given after they have had the vaccine information sheet your jurisdiction requires and a chance to ask questions.
Avoid: A signature before the sheet. Hand it over, give the person time to read it, and ask for questions before they sign.
A record that the person was offered the vaccine, heard the risks of going without it, and chose not to have it.
Avoid: Making the reason compulsory, or arguing with it. Explain the risks once, clearly, and leave the door open.
The details of each dose, written as it’s given, so it can be traced, counted toward a series, and shared.
Avoid: One line for two vaccines. Write a block for each, so you know which went in which arm.
The observation period, any reaction and what you did about it, and when the person is due back.
Avoid: “Tolerated well” with no times. Write when observation started and ended, so the record shows it happened.
A mild illness, even with a low fever, isn’t a reason to delay. Wait only for a moderate or severe illness, and write when the person should come back.
Without them, you can’t find the people who had a recalled batch, or link a reaction to one. Copy both from the vial or box at the time, not from memory.
With two vaccines, a sore, swollen arm the next day only means something if you know what went where. Record a site for each vaccine.
A declination is a choice. If a clinician confirms a reason the person shouldn’t have the vaccine, record it as a medical exemption, so it isn’t offered to them again by mistake.
An egg allergy, even a severe one, is no longer a reason to skip the flu vaccine or watch the person longer. Use the same precautions as for any vaccine.
Vero Scribe drafts the form in your template from the visit, with the person’s consent, or from your dictation: the screening answers, what you discussed, and each vaccine given. You review and edit every section, then copy it into your record or export it to Word or PDF to sign. Vero works in 60+ languages.
Who the person is and which vaccines are offered; screening questions about illness today, allergies and past reactions, pregnancy, a weakened immune system, recent vaccines, bleeding, and fainting; consent after the person has the vaccine information sheet your jurisdiction requires; a declination for someone who says no; and a record of each dose: vaccine, manufacturer, lot number, expiry, dose, route, site, date and time, who gave it, observation, any reaction, and the next dose due.
A signed record that a person was offered a vaccine, was told the risks of going without it, and chose not to have it. Hospitals and other health care employers often ask staff who decline the flu vaccine to sign one, and some ask unvaccinated staff to wear a mask during flu season. A reason is usually optional, and the person can change their mind at any time. A medical contraindication is recorded separately, as an exemption.
Yes. Write the season’s flu vaccine under vaccines offered, and the screening, consent, and record work as they are. For a workplace or pharmacy flu clinic, keep the declination with the consent, so everyone offered the vaccine has one signed form either way.
The vaccine and dose number, the manufacturer, lot number, and expiry date, the dose, route, and site, the date and time, who gave it and where, the version date of the information sheet given, the observation period, any reaction, and the next dose due. The lot number lets you find everyone who had a batch if it’s recalled. Enter the dose in your immunization registry, and give the person a copy.
It depends on where you practice and the setting. In many places consent can be verbal, as long as the person had the information first and you record their agreement. Pharmacies, schools, and workplace clinics often ask for a signature. Follow your organization’s policy and your regulator’s guidance.
Yes. Current guidance says people with an egg allergy, even a severe one, can have any flu vaccine suited to their age and health, with the same precautions and observation as for any vaccine.
Usually 15 minutes, seated, so staff can help if they faint or have an allergic reaction. Many protocols use 30 minutes when there’s a specific concern about allergy, such as a past allergic reaction to another vaccine or an injected medicine. Record the start and end times.
Yes. Copy it, or download it as a Word or text file. No account needed.
A patient leaving or refusing care: the recommendation, capacity, risks in plain words, alternatives, signature or refusal to sign, and the care still given.
A patient’s authorization to release health information: who sends and receives it, what goes, sensitive records, purpose, end date, rights, and the release log.
Consent to a procedure or treatment: benefits, risks, alternatives, capacity, signatures, and the discussion note.
A parent names another adult to consent to their child’s care: dates, what it covers, health details, and signatures.
Consent to clinical photos, video, or audio: what is recorded, each use chosen separately, the device, storage, and withdrawal.
Clinic, outreach, and program notes, drafted for your team’s review.
Counseling notes and patient summaries from the conversation.
Visit notes, forms, and follow-up, drafted for your review.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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