Yellow Fever Form - Park City Vaccines printable pdf download

Park City Vaccines

A division of Travel Health Vaccines Inc

1441 W. Ute Blvd Ste 220, Park City, UT 84098

435/604-0250

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CONSENT FOR YELLOW FEVER VACCINATION

(9 months of age or older)

Print Name:_________________________________________ Date of Birth:___________________

Address:____________________________________________________________________________

City:_______________________________ State:____________ Zip Code:___________________

Phone #:____________________________ Email: ________________________________________

Emergency Contact:_________________________________ Phone Number_____________________

PERSONS WHO SHOULD NOT TAKE THIS VACCINE:

YOU HAVE A HISTORY OF ALLERGY TO EGGS, CHICKEN OR GELATIN



YOU HAVE IMMUNE DEFICIENCIES DUE TO CANCER, ACTIVE HIV, TRANSPLANTATION OR DRUG THERAPY



YOUR THYMUS GLAND HAS BEEN REMOVED OR IF YOU HAVE A THYMUS DISORDER



YOU HAVE RECEIVED ANOTHER “LIVE” VACCINE IN THE LAST 28 DAYS



YF Vaccine Precaution - 60 years or older

If you are 60 years old or greater, you have a higher risk of severe neurological and multi-organ failure



reactions and complications compared to younger age groups. Risks and benefits of vaccination should be

carefully weighed against the destination-specific risk of exposure to consider a medical waiver (See

attachment for more detailed information)

ADVERSE REACTIONS THAT MAY OCCUR

Mild reactions occur in 5% - 30% of people who receive the vaccine. Mild reactions include the

following symptoms:



LOCAL SYMPTOMS: SLIGHT TENDERNESS, REDNESS OR IMFLAMMATION AT THE SITE OF INJECTION LASTING 1-5 DAYS

AFTER VACCINATION



FEVER, HEADACHE, BACKACHE, AND/OR BODYACHES BEGINNING WITHIN SEVERL DAYS AFTER VACCINATION AND

LASTING FROM 5-10 DAYS



LIFE -THREATENING ALLERGIC REACTIONS FROM VACCINES ARE VERY RARE. IF THEY DO OCCUR, IT IS WITHIN A FEW

MINUTES TO A FEW HOURS AFTER THE SHOT. CALL 911 IF YOU HAVE ANY SIGNS OF A SERIOUS ALLERGIC REACTION

WHICH CAN INCLUDE DIFFICULTY BREATHING, HOARSENESS OR WHEEZING, HIVES, PALENESS, WEAKNESS OR FAST

HEART BEAT OR DIZZINESS.

I HAVE READ THE ABOVE INFORMATION AND THE VACCINE INFORMATION STATEMENT SHEET

(VIS from the CDC) AND UNDERSTAND THE INFORMATION. I VOLUNTARILY CONSENT TO RECEIVE

THE YELLOW FEVER VACCINE.

SIGNED:_________________________________________________________________

DATE:______________________

If Child under 18, fill out section below:

Guardian Name (Print):

_______________________________________________________

Guardian signature:_____________________________________________________

DATE:______________

(if patient <18yrs of age>

Yellow Fever Form - Park City Vaccines

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