Tdap Vaccination Consent Form
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1Tdap (Tetanus, Diphtheria, Pertussis) Immunization Consent Form
Date ________________
Name of Student ________________________________
Address_________________________________________________________________
City
Birthdate ____________________
Phone:______________________________
For tracking purposes only, please mark one:
____Medicaid
____No Insurance
____Private Insurance
YES
NO
1. Is the child currently taking medication(s) for any purpose?
___
___
If yes, what medication(s)? ___________________________
2. Does the child have any food or medication allergies?
___
___
If yes, which food or medication? ______________________
3. Has the child had a serious reaction to a vaccine in the past?
___
___
If yes, which vaccine(s) and what occurred?
________________________________________________
4. Has the child received vaccinations in the past four weeks?
___
__
5. Does the child have any neurological disease (brain) or history of
seizures?
___
___
6. Does the child have cancer or is the child on medications that lower
the body’s resistance to infection?
___
___
7. Is the child/teen pregnant or is there a chance she could be?
___
___
I have read, received, and understand the form titled “Tdap Vaccine: What You Should Know”. I have had a chance
to ask questions and these have been answered to my satisfaction. I understand that the vaccination is being given
by the Decatur County Public Health Nurses. The owner and/or operator of the clinic site location, their
subsidiaries, divisions, affiliates, officers, directors, and employees expressly disclaim any responsibility with
respect to the vaccination procedures and I agree to release them from any and all claims arising out of, in
connection with, or in any way related to the receipt of this Tdap vaccine. I give my consent, voluntarily and of my
own free will, to the staff of Decatur County Public Health to give my child the Tdap vaccine. I accept
responsibility for seeking medical attention, with a physician, for my child is he/she experiences any reaction or side
effects.
____________________________________
Parent Signature
Date
To Be Completed by Decatur County Public Health:
Tdap Vaccine
Date Given
Lot # / Mfctr / Site
Nurse Signature
_________
____________________
__________________________
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