Emergency Preparedness

Kern Medical Bioterrorism Response Guide Section 2-C-1 – Smallpox

SMALLPOX VACCINATION CONSENT FORM

I,

(print name)

do hereby give my written consent to be vaccinated. I have had the opportunity to read and I understand that complications can occur after receiving the vaccination. I understand the instructions for caring for the vaccination site. I have had the opportunity to ask questions related to smallpox vaccination and have had my questions answered to my satisfaction. By my signature below, I accept the smallpox vaccination. Patient (Parent or Guardian) Signature: Date:

Lot Number:

Expiration Date:

Distribution center location: Date: / / Name title of person administering vaccination:

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