Assessment, Release, And Consent Form - Tetanus And Diphtheria Vaccination printable pdf download

Assessment, Release, And Consent Form - Tetanus And Diphtheria Vaccination

Tetanus and Diphtheria Vaccination

Adacel®- Tetanus, Diphtheria and Pertussis Vaccination

Assessment, Release, and Consent Form

Date: ____/____/____ V.I.S. Form 11/18/08

Vaccine: _____________________

Lot Number: __________________

QS1 Patient Code: ______________

Shot Location L or R Deltoid Initials_____

Store Location____________

FOR OFFICE USE ONLY

Name:_______________________________________

Date of Birth:_____/______/_______

PLEASE PRINT

(Individual receiving vaccination)

Address: _________________________________________Phone: _______________________

City: _________________ State: _________ Zip Code: _________ County: ________________

Sex:

Male

Female

Primary Physician: ______________________

PLEASE CIRCLE THE ANSWERS TO THE FOLLOWING QUESTIONS:

1. Have you ever had a severe reaction to any vaccine?

YES

2. Do you have any severe food or drug allergies?

YES

For Td ONLY If yes, are you allergic to thimersol?

YES

•

For TdaP ONLY If yes, are you allergic to 2-phenoxyethanol?

YES

•

If yes, are you allergic to latex?

YES

•

3. Do you have a substantial fever (>101.3° F), diarrhea, or vomiting?

YES

4. Did you ever have Guillian-Barre syndrome?

YES

5. Females: Have you had a mastectomy?

YES

After receiving this vaccination there is a risk of pain, redness, and swelling at the injection site, headache,

fever, fatigue, gastrointestinal symptoms, and body aches. Rarely, severe allergic reactions may occur. If

you experience a severe reaction, please contact your physician.

I have read the information or have had it explained to me. I have had a chance to ask questions and these

have been answered to my satisfaction. I understand the benefits and the risks of the above mentioned

vaccinations and ask that the vaccine is given to me, or to the person named above for whom I am

authorized to make this request. I accept responsibility for seeking medical attention for any problems

encountered as a result of this vaccination. I authorize billing of this vaccination to my health insurance. If

for any reason my insurance does not pay for the vaccination, I agree to pay the full amount of the

procedure.

Signature: ____________________________________ Date: ______/______/________

Assessment, Release, And Consent Form - Tetanus And Diphtheria Vaccination

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