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Vaccine Consent without Parent

We are very dedicated to accuracy and high quality of care so we ensure that all our patients have a legal guardian present when they receive their vaccines. However, we do understand that guardians are often busy with work and may not be available to accompany their child for their visits. However, we want to ensure that the guardian understands the specific vaccine(s) their child is receiving that day and consents us to administer it, we are more than happy to complete it without the guardian present. Thank you for following our clinic protocols and supporting our efforts to provide accurate care.

Patient Information

This information will be sent to your provider and will be kept as part of your patient records.

Please review to ensure the details are correct before completion.