Vaccination Consent templatePRO: uses e-signature, publishing needs a Pro plan

A vaccination consent form pairing a signed consent with a pre-screening checklist a clinician reviews on the day: prior reactions, severe allergies, current illness, pregnancy, and immune-related conditions or medications. The checklist's own wording notes that a flagged answer doesn't necessarily rule out vaccination — it routes the conversation to the clinical team, where it belongs.

Use this template Start free — no card

6 questions · Pro to publish · fully customizable

Uses an e-signature question (Pro). You can preview and edit it on Free; publishing needs Pro — or swap the signature for a typed-name question plus a consent checkbox to publish on Free.

E-signature question

Interactive — fill it in like a respondent would.Open full width

What’s inside

The questions this template ships with — rename, reorder, or delete any of them in the builder.

01Patient's full legal nameShort text

02Date of birthDate

03Which vaccine are you scheduled for?Dropdown

04Do any of the following apply to you?Checkboxes

05Have you received this vaccine before?Multiple choice

06Sign to consent to vaccinationE-signature

When to use this template

A pharmacy running seasonal flu clinics that needs consent collected before patients reach the chair
An employer-hosted vaccination day where staff complete consent at their desks instead of queueing with clipboards
A travel clinic collecting consent and screening answers ahead of appointments, with the vaccine chosen from a dropdown
A community health event where volunteers check in attendees who've already signed

Tips to get more from it

The screening checklist is required, and "None of the above" is an option — so every patient gives an explicit answer, and a blank never has to be interpreted
The vaccine dropdown lists six common vaccines; trim it to what your clinic actually stocks so the day's roster exports cleanly by vaccine type
The signature's helper text spells out what signing means — accuracy of the answers and consent to the selected vaccine. The signature field requires Pro to publish; the rest of the form runs on free
The ending tells patients to plan for a 15-minute observation period, which sets expectations before they arrive — adjust it to your clinic's procedure

Questions people ask

Does this form decide whether someone can be vaccinated?

No. It collects screening answers and consent for the clinical team to review — the checklist itself tells patients a flagged answer doesn't necessarily mean they can't be vaccinated. Eligibility decisions stay with the clinician on site.

Can I use this for a workplace flu-shot clinic?

Yes. Share the link with staff ahead of the clinic day, and each submission arrives with the employee's name, date of birth, chosen vaccine, screening answers, and signature.

Do I need a paid plan for the signature field?

Publishing a form containing a signature field requires the Pro plan at $14.99/mo. Everything else in this template — the dropdown, checklist, and date fields — publishes free.