VACCINE ADMINISTRATION CONSENT FORM

I (Input Name below), authorize Atlanta Pediatric Partners

to administer any immunizations as recommended by the American Academy of Pediatrics and the Georgia Department of Health Services, Immunizations Branch to my child

Child’s name

DOB

I have read or had explained to me the information about the respective diseases and vaccines
I had an opportunity to ask questions and any questions were answered satisfactorily
I believe that I understand the benefits and the risks of these vaccines

Signature of Parent/Legal Guardian

Date

ATLANTA PEDIATRIC PARTNERS-4579 South Cobb Dr. SE Suite 300 Smyrna, GA. 30080

Your information will be encrypted.