AIR111-2 (REV. 10/18)
Adult Immunization Administration Record
Practice Name: ����������������������������������������������������������������������
Address: ����������������������������������������������������������������������������
Patient Name: ����������������������������������� Birth Date: ��������������� M F
Address: ������������������������������� City: ��������������� State: ����� Zip: ��������
Parent, Guardian, or vaccine recipient - Please read and initial.
**With the recent change to our child care and school rules there is a slight change in documenting parental requests (consent)
for their child's vaccination.
The rule requires documented written, photographic, electronic or other permanent form of parental request of vaccination.
This means that a hard signature is no longer the requirement. Providers can determine which documentation from the list
above is most appropriate for their office.
Initials
Statement 1: I have read or have had explained to me the information contained in the Vaccine Information
Statements (VISs) about the following disease(s) and vaccine(s): Diphtheria, Tetanus, Pertussis, Polio, Measles,
Mumps, Rubella singly or in combination, Hepatitis A, Hepatitis B, Varicella, Pneumococcal, Meningococcal,
Human Papilloma Virus, Herpes Zoster, and Influenza. I have had a chance to ask questions that were answered
to my satisfaction. I understand the benefits and risks of the vaccine(s) and request that the vaccine(s) indicated
on this form be given to me or the person named on this health record for who I am authorized to make this
request.
Statement 2: I agree to allow the health care provider giving vaccinations to release information about all
vaccinations given to me, or to the person for whom I am authorized to consent, to the Arizona State
Immunization Information System (ASIIS), other health care providers and schools in order to avoid receiving
unnecessary vaccinations and to provide information about what immunizations have been received. I understand
that I am not required to agree to the release of this information in order to receive the vaccinations I request.
If I do not wish this record to be included in ASIIS, I have the option of crossing out the above boxed statement
and initialing it. I understand that by making this decision, I will not have access to my immunization records (in
ASIIS) in the future for schools, college attendance, future jobs/employment, military, etc.
TB Test
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Result TB Test
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signature
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click to sign
signature
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click to sign
signature
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click to sign
signature
click to edit
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