Consent For Tuberculin Skin Test Form

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(UDOH, Bureau of Communicable Disease Control, TB Control 801-538-6096)
Consent for Tuberculin Skin Test
(Do not get tested if you’ve tested positive in the past)
Name:_______________________
DOB__________
Gender: M___ F___
Address: ________________________
Home phone: ______________
________________________
Work phone: ______________
________________________
I understand that if I have an immunosuppressive condition, recent vaccine history,
history of a previous positive PPD, or am sick now, I should discuss this with the test
administrator before proceeding. I have had a chance to have my questions answered,
and agree to be tested. I understand that I must return in 48 – 72 hours to have the test
read, or it will need to be repeated.
Patient signature:_______________________ Today’s Date:_____________
…………………………………………………………………………………………..
Clinic use only
PPD manufacturer:__________________ Lot #____________ Exp. Date_____________ Site: __________
Placed by:_____________________________________
_________________________________________
___________
Print Name
Signature
Date
Reading:_____mm Referred for further evaluation: Y___ N___
Read by:_______________________________________
_________________________________________
___________
Print Name
Signature
Date
(UDOH, Bureau of Communicable Disease Control, TB Control 801-538-6096)
Consent for Tuberculin Skin Test
(Do not get tested if you’ve tested positive in the past)
Name:_______________________
DOB__________
Gender: M___ F___
Address: ________________________
Home phone: ______________
________________________
Work phone: ______________
________________________
I understand that if I have an immunosuppressive condition, recent vaccine history,
history of a previous positive PPD, or am sick now, I should discuss this with the test
administrator before proceeding. I have had a chance to have my questions answered,
and agree to be tested. I understand that I must return in 48 – 72 hours to have the test
read, or it will need to be repeated.
Patient signature:_______________________ Today’s Date:_____________
…………………………………………………………………………………………..
Clinic use only
PPD manufacturer:__________________ Lot #____________ Exp. Date_____________ Site: __________
Placed by:_____________________________________
_________________________________________
___________
Print Name
Signature
Date
Reading:_____mm Referred for further evaluation: Y___ N___
Read by:_______________________________________
_________________________________________
___________
Print Name
Signature
Date

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