Authorization For Immunization Administration

Please correct the errors described below.

authorize Berkeley Pediatric Medical Group (BPMG) to administer the following vaccine/s to my child at the appropriate age/schedule according to ACIP guidelines. I have reviewed the Vaccine Information Statement.

Please note, we often will administer seasonal Flu vaccines as an “add-on” to other vaccines at a visit if your child has not received the vaccine yet that year. By checking above you consent to this.

*All Vaccine Information Statements are available on our website, at

By signing this authorization, I give permission for the staff at BPMG to administer the above immunizations to my child. I may revoke this authorization in writing, at any time.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Email to: or fax to (510) 848-3109

Your information will be encrypted.