How to Fill Out Form C-94

Form C-94 at a glance

What it is: Immunizations C-94 (08/21) is the Addendum to Td (Tetanus, Diphtheria) Vaccine: What You Need to Know Vaccine Information Statement, a consent statement.

Where and when to file: File this consent statement in the patient's chart.

A filled-in Form C-94 example: a parent signs for her son

Form C-94 example filled out, example: a parent signs for her son — Rosa Sample, a parent, fills out the addendum for her son. She checks Tetanus and Diphtheria (Td) for her son Daniel, born May 12, 2010, who is male. The picture shows the signature lines and dates filled in; every value is made up. Rosa signs as the person authorized to make the request (parent or guardian). A witness signs the Witness line, and both dates are March 14, 2026. The Tetanus box and the F box stay empty because the story names Td and a male.

How to fill out Form C-94, box by box

Vaccine to be given

Check the vaccine to be given, Tetanus and Diphtheria (Td) or Tetanus: I agree that the person will get the vaccine checked.

Information about person to receive vaccine

Please print the information about the person to receive the vaccine: Name (Last, First, Middle Initial) and Birthdate (mm/dd/yy).

Sex: circle one, M or F.

Address: fill in the Street, City, County and Zip; State is TX.

Signature and witness

Signature of the person to receive the vaccine or the person authorized to make the request (parent or guardian): sign there and enter the Date.

7. I am an adult who can legally consent for the person to get the vaccine. I freely and voluntarily give my signed permission for this vaccine.

Witness: Date.

More rules for Form C-94

2. I received or was offered a copy of the Vaccine Information Statement (VIS) for the vaccine listed under Vaccine to be given. 3. I know the risks of the disease this vaccine prevents. 4. I know the benefits and risks of the vaccine.

5. I have had a chance to ask questions about the disease the vaccine prevents, the vaccine, and how the vaccine is given. 6. I know that the person will have the vaccine put in his/her body to prevent the disease this vaccine prevents.

Privacy Notice: I acknowledge that I have received a copy of my immunization provider's HIPAA Privacy Notice.

Alterations or changes to this publication is prohibited.

Common questions about Form C-94

Where do I file it?

File this consent statement in the patient's chart.

Sources

[1] Immunizations C-94 (08/21), Addendum to Td (Tetanus, Diphtheria) Vaccine: What You Need to Know Vaccine Information Statement, Texas Department of State Health Services (the Official source link on this page).

Form C-94 PDF Details

File this consent statement in the patient's chart.

Vaccine: Under Vaccine to be given, check Tetanus and Diphtheria (Td) or Tetanus.

Information about person: Name, Birthdate (mm/dd/yy), Sex (circle one), Address.

Signing: The person to receive the vaccine, or the person authorized to make the request (parent or guardian), signs and dates; a witness signs and dates the line.

VIS: I received or was offered a copy of the Vaccine Information Statement (VIS) for the vaccine listed above.

Privacy notice: I acknowledge that I have received a copy of my immunization provider's HIPAA Privacy Notice.

Question	Answer
Form Name	Form C-94
Form Length	1 page
Fillable?	Yes
Fillable fields	16
Avg. time to fill out	3 min
Other names	Form C-94, C-94, Addendum to Td, Texas Addendum to Td Vaccine
Edition	C-94 (08/21)
Official source	Form C-94 (08/21)

Form C-94: Texas Addendum to Td (Tetanus, Diphtheria) Vaccine