Hpv Vaccination Consent Form Nhs printable pdf download

Human papillomavirus (HPV)

Vaccination consent form

The HPV vaccine that protects against cervical cancer is being offered to your daughter at her school. The leaﬂet that

accompanies this form tells you and your daughter about the HPV vaccine. To get the best protection, it is important

that she receives two injections. The second injection will be offered six to 12 months after the first (although it can

be given up to 24 months after). Your school will inform you about the specific timing of the second dose which is

being decided locally. The leaﬂet ‘Your guide to the HPV vaccination from September 2014’ which accompanies this

form includes more information about the vaccine. Please discuss this with your daughter, then complete this form

and return it to the school before the vaccination is due to be given. Information about the vaccinations will be put on

your daughter’s health records, including records at her GP’s surgery and held by the NHS. If you have more questions,

please contact the school nurse or other health professional. For further information go to

Girl’s full name (first name and surname):

Date of birth:

Home address:

Daytime contact telephone number for parent/carer:

NHS number (if known):

Ethnicity:

School:

Year group/class:

GP name and address:

Your daughter will receive her first HPV vaccine in Year 8

_________________

term and the second

HPV vaccine in Year

____ _______________

term.

Consent for two HPV vaccinations

(Please complete one box only)

I want my daughter to receive the full course

I do not want my daughter to have

of two HPV vaccinations

the HPV vaccine

Name

Signature

Parent/Guardian

Date

If, after discussion, you and your daughter decide that you do not want her to have the vaccine, it would

be helpful if you would give the reasons for this on the back of this form (and return to the school).

Any side effects following the HPV vaccination should be reported to the school nurse or your GP

Thank you for completing this form. Please return it to the school as soon as possible.

OFFICE USE ONLY

Date of HPV vaccination

Site of injection

Batch number/

Immuniser

Where administered

expiry date

(please circle)

(please print)

(school, college, GP etc)

L arm

R arm

First

L arm

R arm

Second

Hpv Vaccination Consent Form Nhs

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