Vaccination Consent Form for Measles, Mumps & Rubella (MMR) Vaccine

Vaccination Consent Form For Measles, Mumps & Rubella (MMR) Vaccine

PLEASE COMPLETE IF YOUR CHILD HAS NOT HAD TWO DOSES OF MMR

Child’s full name (first name & surname): M / F / Date of birth:
Home address (including postcode): / Daytime contact number for parent/carer:
NHS number (if known): / Ethnicity:
School: / Year group/class:
GP name & address:
1. If your child has received MMR doses before, please give dates: 1st dose: ………… 2nd dose: ………………….
Please note, if dates above are unknown/not stated, a dose of MMR vaccine will be given if you sign the consent form.
2. Has your child received any vaccines in the last month? YES □ NO □ If yes, what were they? ………………
3. Has your child had a confirmed anaphylactic reaction (or collapse) after a previous immunisation or any medicine or any other substance? YES □ NO □
4. Does your child have any medical conditions including a lowered immunity or neurological condition/brain injury? YES □ NO □
5. Is your child taking any other medication? Yes □ No □
If YES to questions 3, 4 or 5, please give details: …………………………………………………………………………..
5. CONSENT
for Measles, Mumps and Rubella (MMR) Vaccine
I DO want my child to have these vaccines and confirm I have parental responsibility:
Name:
Signature of parent/carer: Date:
NO CONSENT
for Measles, Mumps and Rubella (MMR) Vaccine
I DO NOT want my child to have these vaccines and confirm I have parental responsibility:
Name:
Signature of parent/carer: Date:

Information about the vaccinations will be put on your child’s school nursing and GP health records

FOR OFFICE USE ONLY

Child’s Name: DoB:
Information given re.vaccine and potential side effects? / Yes □ No □
Is the student pyrexial or systemically unwell? / Yes □ No □
Are there any contraindications on the consent form? / Yes □ No □
Could the student be pregnant? (see flowchart) / Yes □ No □ N/A □
If yes to any of the questions above, follow ‘decision making’ flowchart and/or discuss with Immunisation Coordinator.
By giving the vaccines documented below the immuniser is confirming that the patient meets the inclusion criteria in the PGD unless a Patient Specific Direction isdocumented below in communication record.
Date / Site of injection
(please circle) / MMR 1 Batch No. and expiry date / Immuniser
Upper left arm
Upper right arm / Print name:
Signature:
Date / Site of injection
(please circle) / MMR 2 Batch No. and expiry date / Immuniser
Upper left arm
Upper right arm / Print name:
Signature:
Immunisation Communication Record (if needed)
Date/Time: / Notes: / Name, Title & Signature: