Cadet Consent For Medical Treatment Page 4
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2
3
4
5
64
Name
Birthdate
VACCINE
Enter month, day, and year each immunization was given
Circle appropriate item
DOSES
Diphtheria and Tetanus
(DTaP, DTP, Td or DT)
1
/
/
2
/
/
3
/
/
4
/
/
5
/
/
Tetanus, Diptheria and Acellular
Pertussis (Tdap)
1
/
/
2
/
/
3
/
/
4
/
/
5
/
/
Polio (OPV or IPV)
1
/
/
2
/
/
3
/
/
4
/
/
5
/
/
Hepatitis B
1
/
/
2
/
/
3
/
/
4
/
/
5
/
/
Measles – Mumps – Rubella (MMR)
1
/
/
2
/
/
OR Measles Serology
Date
Titer
Varicella (Vaccine or Disease)
1
/
/
2
/
/
Rubella Serology
Date
Titer
Meningococcal (MCV)
1
/
/
2
/
/
Other
1
/
/
2
/
/
Mumps disease diagnosed by a Physician: Date
•
Lab results indicating Immunity will be accepted. Copies of labs must be attached.
•
Immunization records may be obtained from your last school; students must have them to attend school.
•
Please refer to the Vaccine Information Sheet for information regarding vaccines that are required:
_______________________________________________
Physician/Office Stamp
Physician’s Signature
Print Physician’s Name
______________________________________________________
Address
_____________________________________________________________________
Phone _________________________________Fax
______________________________
Date of Exam
:
PRIVATE DENTIST REPORT
OF DENTAL EXAMINATION OF A PUPIL OF SCHOOL AGE
th
Mandatory for 7
Grade
NAME OF CHILD
AGE
SEX
GRADE
SECTION/ROOM
_________________________________________________________________
Last
First
Middle
M
F
ADDRESS
_______________________________________________________________________________________________________________________________________
No. and Street
City or Post
Borough or Township
County
State
Zip
Office
REPORT OF EXAMINATION
TOOTH CHART
RIGHT
LEFT
UPPER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
A
B
C
D
E
F
G
H
I
J
UPPER
LOWER
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
T
S
R
Q
P
O
N
M
L
K
LOWER
UPPER
UPPER
LOWER
LOWER
____________________________________________________
Date of Dental Examination
____________________________________________________
____________________________________________________
Signature of Dental Examiner
Print Name of Dental Examiner
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