Form F-00048 - Authhorization To Receive Tetanus, Diphtheria, Acellular Pertussis (Tdap), Menongococcal Conjugate (Mcv4), Human Papilloma (Hpv), And/or Influenza Vaccine(S)

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Wis. Stats. 252.04
F-00048 (08/2016)
Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap),
Meningococcal Conjugate (MCV4), Human Papilloma Virus (HPV), and/or Influenza Vaccine(s)
Information collected on this form will be used to document authorization for receipt of Tdap, MCV4, HPV, and/or Influenza
vaccine(s) at your child’s school. Information may be shared through the Wisconsin Immunization Registry (WIR) with other
health care providers directly involved with your child to assure completion of the vaccine schedule.
My signature below authorizes my child to receive the following vaccine(s). Check all that apply:
Tdap (Tetanus, diphtheria, acellular pertussis) vaccine [Required (1 dose)]
MCV4 (Meningococcal conjugate) vaccine [Recommended (2 doses)]
HPV (Human papilloma virus) vaccine [Recommended (3 doses)]
Flu Vaccine (Influenza) [Recommended Annual (1-2 doses)]
Patient’s Name (Last, First, Middle Initial)
Date of Birth (mm/dd/yyyy)
Address
P. O. Box
City
County
State
Zip Code
Mother’s Maiden Name
Home Telephone Number
Sex
(
)
Male
Female
Race (Check one)
Ethnicity (Check one)
African American
American Indian or Alaskan Native
Asian
Hispanic or Latino
Non-Hispanic or Latino
Native Hawaiian / Pacific
White
Other
Eligibility Status -
This section must be completed. (Check all that apply)
Native American
Badger Care
Insured, Vaccines Covered
Medicaid Eligible
No Health Insurance
Insured, Vaccines Not Covered
Name of Physician
Name of School
Grade
Name of Parent or Guardian Responsible for Patient (Last, First, Middle Initial)
Relationship to Patient
Okay to share immunization data with Wisconsin Immunization Registry (WIR)?
Yes
No
I have been given a copy and have read, or have had explained to me, information about the disease(s) and vaccine(s) to be
received. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of
the vaccine(s) requested and ask that the vaccine(s) be given to me or to the person named above for whom I am authorized
to make this request.
Wisconsin Medicaid restricts billing recipients for any covered service(s). I understand that if I am a
Medicaid/BadgerCare recipient I cannot be charged an administration fee or asked for any type of donation for the
administration of any vaccine that is being provided.
SIGNATURE - Person to receive vaccine or person authorized to sign on the patient’s behalf.
Date Signed
X
FOR OFFICE USE
Tdap:
route= IM
site (circle one)
RD or
LD
dose number= 1
Manufacturer/Expiration_______________________________________________ Lot No. _____________________
VIS date: 2/24/15
MCV4:
route= IM
site (circle one)
RD or
LD
dose number=
1
or
2
Manufacturer/Expiration_______________________________________________ Lot No.______________________
VIS date: 3/31/2016
HPV:
route= IM
site (circle one)
RD or
LD
dose (circle one)
1 or
2
or
3
Manufacturer/Expiration______________________________________________
Lot No.______________________
VIS date: 3/31/2016
Flu:
route = IM
site (circle one)
RD or
LD or RV
or LV
dose (circle one)
1 or 2
VIS date: 8/7/2015
Manufacturer/Expiration_______________________________________________ Lot No. _____________________
Signature and title of person administering vaccine:______________________________________ Date vaccine administered: ________________
LHD clinic address:______________________________________________________________________________________________________

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