Hpv Consent Form (Page 2 of 2) in pdf

Who should NOT get this vaccine?

Anyone who has had an allergic reaction to a previous dose of Gardasil® or is allergic to yeast, aluminum,

polysorbate 80, L-histidine or sodium borate;

Anyone who has had a severe reaction to another vaccine;

Pregnant women.

Anyone who has a fever or is sick with anything more serious than a cold should wait until they are feeling

better before getting the vaccine.

What are the possible side effects of getting the HPV vaccine?

Some people may have redness, warmth, slight swelling or bruising where the needle was given. Other

common side effects include dizziness, fever, headache, tiredness, muscle aches, nausea. Rarely, side

effects include trouble breathing, a rash, or swelling in the throat and face. See a health care provider if a

serious reaction occurs following vaccination.

The risk from HPV infection is much greater than the risk from the vaccine.

What to Do

Ensure you read and understand the information provided here. Complete the Consent Form on the front,

remove it and return it to your child’s school as soon as possible. Keep the rest of the sheet for your

information. A record of the vaccine administered will be given to your child to bring home.

For More Information

Contact the Hastings & Prince Edward Counties Health Unit Immunization Program at 613-966-5500 x313.

Toll free 1-800-267-2803. TTY 613-966-3036 Mon-Fri 830am-430pm.

Parental Awareness/Consent to Treatment

The Health Care Consent Act states that all persons, regardless of age, may consent to medical treatment,

provided they understand the benefits and risks of the treatment as well as the benefits and risks of not

having the treatment. There is no minimum age in Ontario for informed consent. Students will be

assessed by a nurse at the school clinic, based on the principles of the Health Care Consent Act, to ensure

that informed consent can be obtained. Parents/Legal guardians are encouraged to talk with their children

about the benefits/risks of immunization.

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THE STUDENT NAMED ON THE FRONT HAS ALREADY RECEIVED HPV vaccine on the following

dates:

dose _______/_____/_____

yyyy

Three doses are required for full protection. If all 3 doses have not been received, please sign the

consent form on the front to ensure full protection.

Hpv Consent Form Page 2