Human Papilloma Virus (HPV) 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 twoinjections. The second injection will be given 6-12 months after the first, although this can be up to 24 months. Please discuss this with your daughter, then complete this form and return it to the school within seven days.
Information about the vaccinations will be put on your daughter’s health records, including records at her GP surgery and those held by the NHS.

Please note, young people under the age of 16 years may give or refuse consent if considered competent to do so by nursing staff.

Allsections must be completed.Please return this form to your child’s school within seven days.

Further information can be obtained from the NHS website Alternatively, please contact your school nurse or another health care professional.

Surname ( BLOCK LETTERS) / Forenames / Sex
M/F / Ethnicity * / Date of Birth
Daytime contact number
Landline
Mobile / Address (BLOCK LETTERS) including postcode
School / Family Doctor and Telephone Number
Has your child suffered a reaction to any previous immunisations? / YES / NO
Does your child have an anaphylactic reaction to any substance? / YES / NO
Are they currently being treated for any medical conditions? / YES / NO
Has your child had any immunisations in the past 3 months? / YES / NO

If you have answered yes to any section, please give details and include date(s).

Please tick the appropriate box:

I consent to my child receiving the full course of two HPV vaccinations

I do not want my child to be immunised

Signature of the parent /guardian______Date______

Relationship to young person______

*ETHNICITY CODES

A / White – British / J / Bangladeshi
B / White – Irish / K / Chinese
C / White – Any Other / L / Any Other Asian Background
D / Mixed – White & Black Caribbean / M / Caribbean
E / Mixed – White & Black African / N / African
F / Mixed – White & Asian / P / Any Other Black Background
G / Mixed – Any Other / S / Any Other Ethnic Group
H / Indian / V / Refused
I / Pakistani / Z / Not Stated

For medical use only

Signature of child (for self consent) ______Date______

Fraser competency assessed by______Date______

Date of HPV vaccination / Site of injection / Batch number
+ expiry date / Immuniser/Designation
(PLEASE PRINT) / After care
advice given
First / Left arm / Right arm / YES / NO
Second / Left arm / Right arm / YES / NO

This data must be transcribed on to RiO records in keeping with CSH Surrey record keeping policy

Date / Comments / Action Plan /
Action Taken / Practitioner
(Print name) / Entered on RiO
Practitioner
(Print name)

PGD NUMBER CSH/C&F 001 09/14 Expiry Date 09/17

Vaccine Manufacturer Sanofi Pasteur

Vaccine Gardasil Dose 0.5ml Intramuscular