Form F-42029 - Authorization To Receive Tetanus, Diphtheria, Acellular Pertussis (Tdap) And/or Varicella Vaccine(S)

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Wis. Stats. 252.04
F-42029 (3/09)
Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap) and/or Varicella Vaccine(s)
Information collected on this form will be used to document authorization for receipt of Tdap and/or varicella 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
Tdap (Tetanus, diphtheria, acellular pertussis) vaccine [Required (1 dose)]
my child to receive these
vaccine(s):
Varicella (Chickenpox) vaccine [Required (2 doses)]
Check all that apply:
Patient’s Name (Last, First, Middle Initial)
Mother’s Maiden Name (Last, First, Middle Initial)
Address
P. O. Box
City
County
State
Zip Code
Home Telephone Number
Date of Birth (mm/dd/yyyy)
Gender
(
)
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________________________________________________________ Lot No. _____________________
VIS date: 11/18/08
Varicella: route= SQ site (circle one)
RD or
LD
dose (circle one)
1
or
2
Manufacturer _______________________________________________________ Lot No.______________________
VIS date: 03/01/08
Signature and title of person administering vaccine:_______________________________________________ Date vaccine administered: ______
LHD clinic address:______________________________________________________________________________________________________

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