Consent For Skin Test printable pdf download

Consent For Skin Test

CONSENT FOR TUBERCULIN SKIN TEST

LAST NAME ______________________________________ FIRST NAME __________________ MI ______

ADDRESS __________________________________________ DATE OF BIRTH ______________________

CITY _____________________________________________

STATE ______ ZIP CODE _______________

PHONE _________________________________________________

1. Have you ever had a TB Skin Test?

Yes

2. Have you ever had a positive reaction to a TB Skin Test?

Yes

3. Have you had any immunizations within the past six weeks?

Yes

4. (Women only) If pregnant - have you discussed TB test with your doctor ?

Yes

N/A

Reason test is needed ______________________________________________________________

I have been informed that I am to return to the Massillon City Health Department on Thursday

between 1:00 -3:30 pm to have my skin test read.

By signing this form, I acknowledge that I have received a copy of the Notice of Privacy Practices from

the Massillon City Health Department and I give the Massillon City Health Department permission to

administer a Mantoux Test

Date __________________________

Signature of Patient or Guardian of Minor _______________________________________________

RECORD OF MANTOUX TEST

STEP 1

Date

_____________________

Date Read __________________

Result ___________________

Time

_____________________

Time Read __________________

TUBERSOL Lot # _____________

Read by _________________________________________________

Site ________________________

Given by ____________________

Consent For Skin Test