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 https://www.berkeleypediatrics.com/well-visits-schedules
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: Frontdesk@berkeleypediatrics.com or fax to (510) 848-3109
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use: