Tdap Consent Form - Town Of Stratford - Connecticut printable pdf download

Tdap Consent Form - Town Of Stratford - Connecticut

Birdseye Municipal Complex, 468 Birdseye Street, Stratford, CT 06615

DEPARTMENT

Phone: 203-385-4090 • Fax: 203-381-2048

OF HEALTH

Tdap VACCINE (Tetanus, Diphtheria, acellular Pertussis) CONSENT FORM

INFORMATION ABOUT THE PERSON TO RECEIVE THE VACCINE

LAST NAME:____________________ FIRST NAME:_____________ PHONE # (____)__________

ADDRESS:_____________________ TOWN:___________ ZIP CODE:____________

DATE OF BIRTH:___/___/___

AGE:_____

Please answer the following questions:

DON’T

YES

KNOW

1. Do you have a moderate to severe illness today, with or without a fever?

2. Have you ever had a serious reaction to a pertussis, diphtheria or

tetanus vaccine? If yes, what kind of reaction? ____________________

3. Have you had the Tdap vaccine before (tetanus shot with a pertussis booster)?

4. Are you currently pregnant?

5. Have you ever been diagnosed with Guillain-Barre Syndrome

following an immunization?

6. Do you have an unstable neurological condition or history of a seizure? If

yes, describe. ______________________________________________

7. Do you have allergies to medications, food, vaccine component or latex?

If yes, describe. ______________________________________________

8. When was your last tetanus shot? _________________________________

9. Do you have frequent* contact with an infant less that 12 months old?

Infant age:________ Your relationship to the infant___________________

* Generally defined as living in the same household or providing care for an infant

CONSENT FOR VACCINATION:

I have been provided a copy of the Vaccine Information Sheet (VIS) and have read it or have had the

information about tetanus, diphtheria and pertussis diseases and the Tdap vaccine. I have had a

chance to ask questions that were answered to my satisfaction. I believe I understand the benefits

and the risks of the vaccine. I request that the vaccine be given to me.

Signature: ____________________________________________ Date: ___/___/___

VACCINE

DATE

MANUFACTURER/

ROUTE/

VIS

Signature and title of person

ADMIN.

LOT NUMBER

SITE

administering vaccine

Tdap/

GSK

Boostrix

1-14-11bb

Tdap Consent Form - Town Of Stratford - Connecticut

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