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Vaccine Acceptance Form
RECOMMENDED VACCINE(S): A SCCHD nurse has explained the purpose, risks, and benefits of the recommended vaccine(s). I am accepting the vaccine(s) offered today:
Hepatitis A
IPV
PCV13
Varicella
Hepatitis B
MenACWY
PPSV23
TB Test
HPV
Men B
Tdap/Td
COVID-19
Influenza
MMR
Consent to complete series as appropriate for selected vaccines
Client Information
EMR#
Client First Name
Client Last Name
Parent/Guardian: Please upload a photo of your driver's license or government based ID
Drop files or click here to upload
Signature of Responsible Party
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Date
Date (mm/dd/yyyy)
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