Consent
Form
Meningococcal
B
Vaccine
Patient Name
Patient Date of Birth:
Phone
Address
Student's School
Please select
Coal City Elementary
Fayetteville PK-8
Independence Middle School
Independence High School
New River Intermediate
New River Primary
Nicholas County High School
Oak Hill High School
Oak Hill Middle School
Summersville Middle School
Valley Pk-8
Other
Please select
Check the vaccine to be administered below. Please review the Vaccine Information Statement here for
Meningococcal B
Vaccine.
Meningococcal B Vaccine
I have read the information in the Vaccine Information Statement about the disease and vaccine. I understand the benefits and risks of the vaccine. I understand that this is a two vaccine series. By signing below, I request the vaccine selected be given to the person named on this consent who I am authorized to sign for. I understand NRHA may release immunization records to other medical or school personnel on as as needed basis with the information being treated in a confidential manner.
Parent/Guardian Name
Parent/Guardian Signature
Clear
Date
04
/
02
/
2025
Submit
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