Form C-112 - Addendum To Shingles Vaccine Information Statement - Texas Department Of State Health Services

Texas Department of State Health Services

Addendum to Shingles

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  benefits  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:

Shingles Vaccine

For  Clinic/Office  Use

Information about person to receive vaccine (Please print)

Clinic/Office   A ddress:

Name: Last

First

Middle Initial

Birthdate

Sex

(circle one)

(mm/dd/yy)

Date Vaccine Administered:

M F

Vaccine Manufacturer:

Address: Street

City

County

State

Zip

TX

Vaccine Lot Number:

Signature of person to receive vaccine or person authorized to make the request (parent or guardian):

Site of Injection:

x

Signature of Vaccine Administrator:

Date

Title of Vaccine Administrator:

x

Witness

Date

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 http://

 for  more  information  on  Privacy  Notification.  (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 VIS Revision 10/06/09

C-112 (10/09)