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Personal Information

Name
Address

Health Related Information

Are you feeling sick or have high fever?
Are you have any allergies?
Have you experienced any severe reaction after getting a vaccine?
Do you have any of the following health condition? (Select all that apply)
Do you any of the following?
Have you received any vaccine in last 15 days?

Emergency Contact Information

Name

Vaccine Consent

Clear Signature
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Are you looking for a vaccine consent form template to take consent from your patients when they attend a healthcare appointment?

Use this detailed and customizable template to streamline the process of requesting consent from your patients.

Is COVID-19 Vaccine Consent Private?

Covid-19 vaccines documentation like this vaccine consent form template are confidential medical information and can’t be shared. With WPForms Pro, you can store the form entries in WordPress so that only logged in users with the correct permissions can see them.

What Should Be Included In the Vaccine Consent Form?

Your vaccine consent form should capture complete details related to the patient and their health condition.

In the personal information section, you should collect personal information such as the patient’s name, age, date of birth, phone number, email address, and home address.

You should complete information related to the patient’s health condition. Ask them everything related to their health such as if they have any allergies, they are feeling sick, they have any minor or major health condition, their vaccination record, and more.

Your form should include emergency contact information like the contact’s name, phone, and relation to the patient.

Finally, you should take consent from the patient and collect their signature.

Features of WPForms’ Vaccine Consent Form

Using WPForms’ advanced drag and drop visual form builder, you can easily add, edit, or remove form fields to customize your form.

You can also include multiple choice fields, checkboxes, dropdowns, and more to the form to collect additional information about their health condition.

With the signature addon, you can collect e-signatures from the patients to take their consent for the vaccine.

Aside from the aforementioned form fields, you can ask relevant health related questions to the patients using the conditional logic feature.

Use WPForms’ Vaccine Consent Form Template

With this vaccine consent form template, you can reduce contact time and collect consent, e-signatures, and health-related information online.

So, what are you waiting for? Get started with WPForms today to create your own vaccine consent form template. Signing up with WPForms gives you access to our vaccine consent form template and hundreds of other pre-made form templates.