Milford Health Department Immunization Clinic- Vaccine Permission Form

Please complete all required fields below.  The Vaccine Information Sheet (VIS) for each vaccine is now available after you select "Yes" to indicate your plan to have it administered to you. Please read and print these documents as they provide you details on the disease and the vaccine along with its benefits and risks.

Insurance:
Race (Select all that apply)
Ethnicity (select all that apply)
Vaccine to be given:

Please read and print the Vaccine Information Sheet (VIS) listed below for the vaccine you plan to have administered to you. This information provides you details on the disease and the vaccine along with its benefits and risks.  

DTaP - VIS/Information sheet

Please read and print the Vaccine Information Sheet (VIS) listed below for the vaccine you plan to have administered to you. This information provides you details on the disease and the vaccine along with its benefits and risks.  

Hepatitis A - VIS/Information sheet

Please read and print the Vaccine Information Sheet (VIS) listed below for the vaccine you plan to have administered to you. This information provides you details on the disease and the vaccine along with its benefits and risks.  

Hepatitis B - VIS/Information sheet

Please read and print the Vaccine Information Sheet (VIS) listed below for the vaccine you plan to have administered to you. This information provides you details on the disease and the vaccine along with its benefits and risks.  

HIB - VIS/Information sheet

Please read and print the Vaccine Information Sheet (VIS) listed below for the vaccine you plan to have administered to you. This information provides you details on the disease and the vaccine along with its benefits and risks.  

Chickenpox - VIS/Information sheet

Please read and print the Vaccine Information Sheet (VIS) listed below for the vaccine you plan to have administered to you. This information provides you details on the disease and the vaccine along with its benefits and risks.  

MCV4 - VIS/Information sheet

Please read and print the Vaccine Information Sheet (VIS) listed below for the vaccine you plan to have administered to you. This information provides you details on the disease and the vaccine along with its benefits and risks.  

PCV13 - VIS/Information sheet

Please read and print the Vaccine Information Sheet (VIS) listed below for the vaccine you plan to have administered to you. This information provides you details on the disease and the vaccine along with its benefits and risks.  

MMR - VIS/Information sheet

Please read and print the Vaccine Information Sheet (VIS) listed below for the vaccine you plan to have administered to you. This information provides you details on the disease and the vaccine along with its benefits and risks.  

HPV - VIS/Information sheet

Please read and print the Vaccine Information Sheet (VIS) listed below for the vaccine you plan to have administered to you. This information provides you details on the disease and the vaccine along with its benefits and risks.  

IPV - VIS/Information sheet

Please read and print the Vaccine Information Sheet (VIS) listed below for the vaccine you plan to have administered to you. This information provides you details on the disease and the vaccine along with its benefits and risks.  

Tdap - VIS/Information sheet