Vaccine Schedule Confirmation Child's Name First Last Pneumococcal2 months (first dose) MM slash DD slash YYYY 4 months (second dose) MM slash DD slash YYYY 6 months (third dose) MM slash DD slash YYYY 12 – 15 months (fourth dose) MM slash DD slash YYYY Inactivated Poliovirus2 months (first dose) MM slash DD slash YYYY 4 months (second dose) MM slash DD slash YYYY 6 –18 months (third dose) MM slash DD slash YYYY 4 – 6 years (fourth dose) MM slash DD slash YYYY InfluenzaYearly, starting at 6 months.Two doses given at least four weeks apart are recommended for children who are getting the vaccine for the first time and for some other children in this age group. MM slash DD slash YYYY Measles, Mumps, Rubella12 – 15 months (first dose) MM slash DD slash YYYY 4 – 6 years (second dose) MM slash DD slash YYYY Varicella12 – 15 months (first dose) MM slash DD slash YYYY 4 – 6 years (second dose) MM slash DD slash YYYY Hepatitis A12 – 23 months (first dose) MM slash DD slash YYYY Second dose MM slash DD slash YYYY The second dose should be given six to 18 months after the first dose.Legal SignatureName of physician or public health personnelSignature of a physician or public health personnel verifying immunization information above.Legal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. 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In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. 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