Vaccination Consent template
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.
8 questions · works on the free plan (500 responses/month) · fully customizable
- E-signature question
What’s inside
The questions this template ships with — rename, reorder, or delete any of them in the builder.
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.
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