(For minors aged 16 and 17 years)
Child's Name: ___________________________________________Instructions for Form NC- 100
Use of the parental consent form allows clients ages 16 and 17 years of age to access immunization services without the presence of an adult; promoting compliance to immunization recommendations.
1. The client must be 16 years or older to use the consent form.
2. The consent form should be completed in ink and signed by the client’s parent or legal guardian.
3. The consent form applies to immunization services only and is valid for a period of twelve (12) months.
The consent covers all immunizations given during that 12 month time period.
4. Minors will be charged for immunizations according to their parent’s income (or TennCare Provider).
1. Forms will be available upon request from the Supply Room to all clinics administering immunizations. Forms may also be given to secondary schools and vocational centers upon request.
2. Forms are to be completed by the parent/legal guardian and presented to clinic personnel prior to the registration process. All information blanks of the form must be completed. Do not proceed with administration of the vaccine if any of the requested information has been omitted.
3. The nurse will contact the parent/legal guardian by phone for any additional information needed to immunize the minor and document this process in the client’s record.
4. The completed consent form will be place in the client’s medical record directly behind the regular permission for services form. The form is a permanent part of the medical record.
5. The minor must sign the immunization record in the chart for each vaccine to be administered. A notation should be made on the immunization record that the Parental Consent form (NC-100) was used.
The following information must be completed before your child can receive immunization services. Please contact us at 423-209-8190 if you need any assistance with this process.
Is your child allergic to any food or medicine?
_____ yes ______no
If yes, please list the allergies: __________________________________________________________
Did your child have any reaction to previous immunizations?
______ yes _______ no
If yes, what was the immunization?
What kind of reaction did she/he have (circle all that apply):
- temperature of 104 or greater
- convulsion or seizures
- breathing problems
- other (please describe)
I give the Chattanooga-Hamilton County Health Department permission to give my child ___________________________ any immunization due now and during the next twelve months.
Parent/Guardian Signature Date
Telephone number where parent/guardian can be reached for additional medical information or in the case of an emergency:
Home _____________________ Work ___________________
Other emergency contact if parent cannot be reached:
Name: _________________ Phone:____________________
You may be eligible to receive immunization services at a discount. In order for us to determine if you qualify for a discount please provide the following information:
Gross monthly income _____________
Number in household ____________
If you would like for us to bill TennCare, your child must bring his/her TennCare card with him/her at the time of service.