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Vaccine Consent Form (English)

Bellevue Pediatrics

Welcome to Bellevue Pediatrics, we strive to keep all our patients safe and healthy. To ensure the health and wellness of our patients, we follow the CDC (Centers for Disease Control) and AAP (American Academy of Pediatrics) guidelines for vaccines administration. Declining required vaccines or schedule of vaccines will result in Bellevue Pediatrics declining to be your child(ren)'s health care provider

DATE OF BIRTH

Please visit the following website for the required vaccines and schedules https://www.cdc.gov/vaccines/schedules/easy-to-read/child-easyread.html ******THIS CONSENT IS NOT FOR THE COVID-19 VACCINE AND FLU VACCINE*******

Date of Birth
* Required field