In order to protect my patient's well being, I have taken the following steps to guarantee that the vaccines I will use will contain no damaging contaminants.
I have a thorough understanding of the risks and benefits of all the medications that I prescribe for or administer to my patients. In the case of (Patient's name) __________________________— , age ________— , whom I have examined, I find that certain risk factors exist that justify the recommended vaccinations. The following is a list of said risk factors and the vaccinations that will protect against them:
Risk Factor ____________________________________________