ST. ANNE GENERAL HOSPITAL, INC. Document No.

:
P. GOMEZ ST. BRGY. IBABANG DUPAY RED-V,
LUCENA CITY , QUEZON PROVINCE 4301, PHILIPPINES Revision No.:
Tel No. (042)710 - 2218/ 710 – 3506
saghiofficial@yahoo.com.ph Revision Date:
VACCINATION RECORD WITH CONSENT
Name: Date:
Age: Sex: Status: Birthday:
Address:

Religion: Contact Number: Place of Birth:

Health History completed by: ▢ Patient ▢ OH Nurse ▢ OH Physician ▢ Guardian

1. Are you well today? ▢ Yes ▢ No (If no, describe): ____________________________________________________________________________________________

2. Do you have any allergies? ▢ Yes ▢ No (If yes, describe): ___________________________________________________________________________________
3. Do you have any health conditions that require regular visits to the doctor? ▢ Yes ▢ No (If yes, describe):
________________________________________________________________________________________________________________
4. Do you have any conditions that can suppress your immune system (i.e. HIV infection, problems with spleen, organ transplant, etc.)?
▢ Yes ▢ No (If yes, describe): ___________________________________________________________________________________________________________________
Note: Tell the nurse or doctor if you are taking treatment, i.e. steroids, chemotherapy, radiotherapy, etc.
5. Have you experienced a reaction to a vaccine in the past? ▢ Yes ▢ No (If yes, describe): __________________________________________________
_________________________________________________________________________________________________________________
6. Are you pregnant or considering becoming pregnant within a month? ▢ Yes ▢ No ▢ N/A

Patient/Guardian’s Name and Signature: _____________________________________________________ Date: _______________________

Verbal consent:
The patient/guardian has been made aware of the benefits and the risks of the vaccine(s) offered to the above person and consents for the
identified person to be immunized on the following date: _______________________________________________________________________
The patient/guardian has agreed to complete the Vaccination Consent Form provided to him/her and agreed to forward the completed form to
the immunization provider. Signature of provider’s representative: _______________________________________________________________
▢ Td – Tetanus, diphtheria ▢ IPV – inactivated polio
▢ MMR – measles, mumps, rubella ▢ Rabies (series)
▢ Hepatitis A (series) ▢ HRIG – Human Rabies Immune Globulin
▢ Hepatitis B (series) ▢ HBIG – Hepatitis B Immune Globulin
▢ Hepatitis A & B (series) ▢ Meningococcal (conjugate or polysaccharide)
▢ Influenza ▢ Varicella
▢ Pneumococcal (conjugate or polysaccharide ▢ Typhoid (oral or injectable)
▢ Cholera ▢ Tdap – tetanus, diphtheria, pertussis
Others: _____________________________________________ Others: _____________________________________________

IMMUNIZATION RECORD
No. in
Vaccine Manufacturer Lot # Site Route Dose Date Given by:
series

WAIVER AND RELEASE. I hereby release, forever discharge and hold harmless St. Anne General Hospital, ICC members, nurses, doctors, and all other
employees, agents, or those representing the hospital and it’s director/s, officers employees, agents and assignees from any and all liability, claims, demands,
and causes of action of whatever kind nature, either in law or equity, which may hereafter arise from my receipt of the vaccine. I understand and acknowledge
that this Vaccination Record with Consent discharges the Releasees from any liability or claim that may arise as a result of my receipt of the vaccine/s, with
respect to any bodily injury, including any mental injury, illness, death or property damage that may result. I understand that Releasees do not assume any
responsibility or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance, in the
event of injury, illness, death, or property damage, unless otherwise expressly governed by and interpreted in accordance with the laws of the Philippines. I
agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such
clause or provision shall not affect the remaining provisions of this consent.

Patient/Guardian Name and Signature: ________________________________________________________________________________________ Date _____________________________________