Hpv Consent Form

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Human Papillomavirus (HPV) School Immunization Program
Fact Sheet / Consent Form
What is human papillomavirus (HPV)?
HPV is a common virus. Three out of four Canadians will have at least one HPV infection in their lifetime.
There are over 100 HPV strains or types. In Canada, strains 16 and 18 cause 70% of cervical cancer. Strains
6 and 11 cause 90% of genital warts.
How can someone get HPV?
HPV is most commonly spread by skin to skin contact during intimate sexual activity with an infected partner.
Some people never get symptoms but they still carry the virus and can infect their sexual partner(s).
What are the symptoms of HPV infection?
Most HPV infections do not have any symptoms. Symptoms can occur months after being infected. When
someone gets infected, they can develop genital warts, which are usually painless but may itchy and
uncomfortable. In some people, the virus can lead to cervical cancer. There are about 400 deaths from
cervical cancer each year in Canada.
Is there a vaccine to prevent HPV infection?
Some HPV infections can be prevented with a vaccine. The vaccine Gardasil® is free to all females in grades
8 through 12. Gardasil® is highly effective against the four HPV strains that the vaccine protects against
(strains 6, 11, 16 and 18).
Is the Gardasil® vaccine safe?
Yes, studies show that it is safe. Serious side effects are rare. Gardasil® was licensed in Canada after many
studies showed it was safe and effective. Over 111 million doses have been given worldwide. Countries
where the vaccine is used, including Canada, continue to monitor its safety. There is no risk of getting an HPV
infection from the vaccine because the vaccine does not contain the live virus.
What else do I need to know about the Gardasil® vaccine?
nd
Three doses are required for full protection. The ideal dosing schedule is the 2
dose given 2 months after the
rd
first, and the 3
dose given 6 months after the first. A shorter schedule which also gives full protection can be
used in order to give all 3 doses at school-based clinics during the school year. The vaccine is most effective
when given before becoming sexually active. Studies have shown good protection for seven years and likely
longer. In the future, a booster dose may be required.
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HUMAN PAPILLOMAVIRUS (HPV) VACCINE CONSENT FORM
FEMALE STUDENT INFORMATION:
Last Name _______________________________________ First Name ________________________
Birth Date: year_________ month _________ day ____ School ________________________ Room/Teacher _________
Ontario Health Card # _____________________________________________________
PLEASE CHECK ALL THAT APPLY:
 YES, I ask that the student named above be vaccinated with the HPV vaccine (up to 3 doses).
 NO, I do NOT wish the above student to be vaccinated with the HPV vaccine.
 The above student has received one or more doses of HPV vaccine (COMPLETE DATES ON REVERSE….)
I have read or had explained to me the information about the HPV vaccine. I have had the chance to ask questions
which were answered to my satisfaction. I understand the risks and benefits of receiving the HPV vaccine.
Date __________ Signature _______________________________ Name (please print) ___________________________
Home Phone (
) _____________________ Work or Cell Phone (
)_________________________________________
This information is collected under the authority of sections 2 and 5 of the Health Protection and Promotion Act and Ont. Reg. 585/94 under the Health Cards and Numbers
IMM-82
Control Act and Section II under the Immunization of School Pupils Act for the purpose of maintaining an immunization record for this student. For more information, contact the
Freedom of Information Coordinator, Hastings & Prince Edward Counties Health Unit, 613-966-5500.
2014/07/15

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