Form C-106 at a glance
What it is: Addendum to Hepatitis B Vaccine, C-106: I agree that the person named in Information about person to receive vaccine will get the vaccine checked in Vaccine to be given.
Who signs: An adult who can legally consent for the person named in Information about person to receive vaccine to get the vaccine gives signed permission.
A filled-in Form C-106 example: a parent consents to the vaccine
How to fill out Form C-106, box by box
Vaccine to be given
Vaccine to be given: Hepatitis B Vaccine.
Information about person to receive vaccine (Please print)
Under Information about person to receive vaccine (Please print), enter the Name (Last, First, Middle Initial), the Birthdate (mmddyyyy), and the Address (Street, City, County, Zip).
Signatures and dates
Enter the Signature of person to receive vaccine or person authorized to make the request (parent or guardian) after X, and the Date.
Witness: enter the Signature after X, and the Date.
More rules for Form C-106
Statements 2 to 6: I received or was offered a copy of the Vaccine Information Statement (VIS) for the vaccine listed. I know the risks of the disease this vaccine prevents and the benefits and risks of the vaccine. I have had a chance to ask questions. I know that the person named will have the vaccine put in his/her body.
Privacy Notice: I acknowledge that I have received a copy of my immunization provider's HIPAA Privacy Notice.
Sources
[1] Form C-106 (01/25), Addendum to Hepatitis B Vaccine, Texas Department of State Health Services (the Official source link on this page).
