Vaccines

Vaccine Consent Form

Mercy Pediatric Clinic requires signed consent forms prior to administering vaccinations to patients in the absence of their parents or guardians.

The consent form needs to be signed each time a minor either 1) attends an appointment alone or 2) is accompanied by someone other than the parent/guardian and who has no prior permission on file to discuss the patient’s health.

Download the vaccine consent form (PDF) and have your child’s caregiver bring it with them to the appointment or email it to us at peds@mercycare.org.

If you have any questions or concerns, please call us at (319) 861-7900.