Deborah L. Ungerleider, MD, LLC
Deborah L. Ungerleider, MD, LLC

Vaccine Consent



I give consent for the following vaccine(s) to be given, in my absence, to my child(ren) by Dr. Deborah Ungerleider or her office nurse, in my absence, for my child (children),









Parent/Legal Guardian Name & Signature



Street Address



City, State and Zip Code



Telephone Number




To print out this form, click on the link below.

Vaccine consent.doc
Microsoft Word document [22.0 KB]

Where to Find Us:

Deborah L. Ungerleider, MD, LLC

44 Godwin Ave Suite 100

Midland Park, NJ 07432


(201) 444-8389


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© Deborah L. Ungerleider, MD, LLC