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    Pediatric Vaccine Review Consent

    Uploaded by

    Raducu Mihaitza
    The parent is requesting a review of their child's vaccination records. The office visit for this review costs $129.99, which does not cover any vaccines that may be recommended. The consultation fee is non-refundable. The form then lists various pediatric vaccines that may be recommended, along with their individual costs that are in addition to the $129.99 fee.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Pediatric Vaccine Review Consent

    Uploaded by

    Raducu Mihaitza
    21 views1 page
    The parent is requesting a review of their child's vaccination records. The office visit for this review costs $129.99, which does not cover any vaccines that may be recommended. The consultation fee is non-refundable. The form then lists various pediatric vaccines that may be recommended, along with their individual costs that are in addition to the $129.99 fee.

    Original Description:

    un test

    Original Title

    Pediatric Vaccine Review Consent (1)

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    The parent is requesting a review of their child's vaccination records. The office visit for this review costs $129.99, which does not cover any vaccines that may be recommended. The consultation fee is non-refundable. The form then lists various pediatric vaccines that may be recommended, along with their individual costs that are in addition to the $129.99 fee.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    21 views1 page

    Pediatric Vaccine Review Consent

    Uploaded by

    Raducu Mihaitza
    The parent is requesting a review of their child's vaccination records. The office visit for this review costs $129.99, which does not cover any vaccines that may be recommended. The consultation fee is non-refundable. The form then lists various pediatric vaccines that may be recommended, along with their individual costs that are in addition to the $129.99 fee.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Pediatric Vaccination Review Consent Form 66

    Patient Name: Test Test

    Date of Birth: 03-03-1998

    Phone Number: (702)000-0000

    I, the parent/guardian, am requesting a review of my child’s vaccination records. I acknowledge that the cost is $129.99 for the office visit with a Clinician to
    review my child’s records and making recommendations based on CDC (Centers for Disease Control) guidelines.

    The office visit fee of $129.99 does NOT cover the costs any vaccines.
    I understand the cost of the consultation is non-refundable under any circumstances.

    Vaccines that may be recommended and cost in addition to the $129.99 consultation fee:

    Pediatric Hepatitis B $79.99 per dose


    Pediatric Hepatitis A $79.99 per dose
    Influenza $49.99

    MMR $149.99 per dose


    Varicella $269.99 per dose
    HPV $449.99 per dose

    Tdap $84.99
    Dtap $79.99
    Polio $89.99
    Meningitis $204.99

    Pneumovax23 $199.99
    Prevnar13 $409.99
    Prevnar20 $399.99

    Parent or Guardian Signature:

    Date: 01-16-2023

    e7 Health
    500 E. Windmill Lane Suite 155 www.e7health.com 2051 N. Rainbow Blvd Suite 100
    Las Vegas, NV 89123 Las Vegas, NV 89108
    Ph: 702-800-2723 Ph: 702-800-2723

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