Informed consent for administration of one or more vaccines to a minor patient. References the CDC Vaccine Information Statement (VIS), captures screening questions, and documents parent/guardian authorization. Suitable for primary care, pediatric, and public health immunization clinics.
The Pediatric Vaccine Administration Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (parent) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, healthcare, pediatric, vaccine, immunization, parent guardian. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Pediatric Vaccine Administration Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Date:** ___________ **Clinic / Practice Name:** ___________ **Administering Provider / Nurse:** ___________ **Child's Name:** ___________ **Child's Date of Birth:** ___________ **Child's Weight (kg):** ___________ **Parent / Legal Guardian Name:** ___________ **Relationship to Child:** ___________ **Parent / Guardian Phone:** ___________ --- ## Vaccine Information Statement (VIS) Acknowledgment Federal law (National Childhood Vaccine Injury Act of 1986, 42 U.S.C. § 300aa-26) requires that a current CDC Vaccine Information Statement be provided before each dose of certain vaccines. I confirm that I received and reviewed the current VIS for each vaccine listed below. **Vaccines to Be Administered Today** ___________ *List each vaccine by full name (e.g., DTaP, IPV, MMR, Varicella, Hep B, Hep A, PCV15, Hib, Rotavirus, Influenza, HPV, MenACWY, MMRV). Include lot number and manufacturer once available.* **VIS Dates Reviewed:** ___________ *Record the edition date printed on each VIS provided.* ---