Form C-94 - Texas Department Of State Health Services Addendum To Tetanus And Diphtheria (Td) And Tetanus, Diphtheria, And Pertussis (Tdap) Vaccine Information Statement


Texas Department of State Health Services
Addendum to Tetanus and Diphtheria (Td) and
Tetanus, Diphtheria, and Pertussis (Tdap)
Vaccine Information Statement
1. I agree that the person named below will get the vaccine checked below.
2. I received or was offered a copy of the Vaccine Information Statement (VIS) for the
vaccine listed above.
3. I know the risks of the disease this vaccine prevents.
4. I know the benefits and risks of the vaccine.
5. I have had a chance to ask questions about the disease the vaccine prevents, the vaccine,
and how the vaccine is given.
6. I know that the person named below will have the vaccine put in his/her body to prevent
the disease this vaccine prevents.
7. I am an adult who can legally consent for the person named below to get the vaccine.
I freely and voluntarily give my signed permission for this vaccine.
Vaccine to be given:
Td (Tetanus and Diphtheria) Vaccine
For Clinic/Office Use
Information about person to receive vaccine (Please print)
Clinic/Office Address:
Name: Last
Middle Initial
(circle one)
Date Vaccine Administered:
Address: Street
Vaccine Manufacturer:
Vaccine Lot Number:
Signature of person to receive vaccine or person authorized to make the request (parent or guardian):
Site of Administration:
x __________________________________________________________ Date ____________
Signature of Vaccine Administrator:
__________________________________________________________ Date ____________
Title of Vaccine Administrator:
PRIVACY NOTIFICATION - With few exceptions, you have the right to request and be informed about information that the State of Texas collects about
you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that
is determined to be incorrect. See for more information on Privacy Notification. (Reference: Government Code, Section
552.021, 552.023, 559.003, and 559.004)
Privacy Notice: I acknowledge that I have received a copy of my immunization provider's HIPAA Privacy Notice.
Notice: Alterations or changes to this publication is prohibited without the express
written consent of the Texas Department of State Health Services, Immunization Branch.
Instructions: File this consent statement in the patient’s chart.
Texas Department of State Health Services
CDC Interim VIS Revision 11/18/08
C-94 (11/08)


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