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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

Tetanus

Tdap

For Clinic/Office Use

Information about person to receive vaccine (Please print)

Clinic/Office Address:

Sex

Name: Last

First

Middle Initial

Birthdate

(circle one)

(mm/dd/yy)

Date Vaccine Administered:

M F

Address: Street

City

County

State

Zip

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:

Witness

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)

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

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