Form

General consent form template for immunisation

This template form is for health professionals to give to parents/guardians for them to give permission for their child to be vaccinated.

• From: Public Health England
• Published: 15 October 2013
• Last updated: 28 October 2013 — See all updates

This publication was withdrawn on 10 April 2018

Please see vaccine specific example consent forms for human papillomavirus (HPV), MenACWY and flu.

Documents

General consent form template for immunisation

MS Word Document, 417 KB

This file may not be suitable for users of assistive technology.

Request an accessible format.

If you use assistive technology (such as a screen reader) and need a version of this document in a more accessible format, please email publications@phe.gov.uk. Please tell us what format you need. It will help us if you say what assistive technology you use.

Details

This form is for health professionals to give to parents, either by hand or by post, preferably with an accompanying information leaflet. It has been produced in a template format in response to requests for a single ‘generic’ consent form that can be adapted for use with any vaccine rather than having a lot of individual vaccine-specific forms.

This template can be downloaded and adapted on screen, with the name of the vaccine and other details inserted as appropriate. Alternatively, it can be printed out and annotated by hand and then photocopied if desired.

Published 15 October 2013
Last updated 28 October 2013 + show all updates

1. 28 October 2013

   Uploaded a new version of the consent form. Updated the narrative in the summary and detail section.

2. 15 October 2013

   First published.