469-241-1954Consent Form/

VIS (Vaccine Informational Sheet) Receipt Form

Vaccines

/ Sign below if statement is true: / VIS
A D U / Anthrax / I am not allergic to latex and have never had Guillain Barré syndrome (GBS). / VIS CDC
03/10/10
A D U / Hepatitis A / I am not allergic to aluminum hydroxide or sodium borate. / VIS CDC
03/21/06
A D U / Hepatitis B / I am not hypersensitive to yeast / VIS CDC
0 7/18/07
A D U / Twinrix / See Hepatitis A and Hepatitis B. I am also not allergic to neomycin.
A D U / Human Papillomavirus Vaccine / I am not allergic to yeast. I am not pregnant or breast feeding.(Gardasil)
I am not allergic to latex. (Cervarix) / VIS CDC

0 3/30/10

A D U / Influenza / I am not allergic to eggs or egg products. I am not allergic to gelatin or gelatin-containing products. I have not had Guillian Barre syndrome.
Flu mist. (I do not have long-term health problems with: - heart disease - kidney or liver disease - lung disease - metabolic disease, such as diabetes - asthma - anemia, and other blood disorders and am between 2 and 49. / VIS CDC
08/10/10
8/10/10
A D U / Japanese Encephalitis / I am not allergic to Protamine Sulfate (Ixiaro) / VIS CDC
3/1/10
A D U / Measles, Mumps, Rubella (MMR) / I am not allergic to neomycin, gelatin or gelatin-containing products, I am not immunosuppressed, I have not received an antibody-containing blood product in the last 11 months. I have no history of thrombocytopenia or thrombocytopenic purpura / VIS CDC
3/13/08
A D U / Meningococcal /

I am not allergic to lactose (Menomune)

I am not allergic to phosphate buffers (Menactra)

/

VIS CDC

01/28/08

A D U / Pneumococcal /

I am not allergic to phenol.

/

VIS CDC

10/06/09

A D U / Polio / I am not allergic to neomycin, streptomycin or polymyxin B / VIS CDC
01/01/00
A D U / Rabies / I am not allergic to chicken protein, neomycin, gelatin/gelatin-containing products, chlortetracycline, amphotericin B or ovalbumin. / VIS CDC
10/06/09
A D U / Shingles / I am not allergic to gelatin or neomycin. I do not have a weakened immune system. I am not pregnant. I am at least 50 years old. / VIS CDC
10/06/09
A D U / Tetanus/Diphtheria / I am not allergic to aluminum potassium sulfate / VIS CDC
11/18/08
A D U / Tetanus/Diphtheria/Pertussis (Tdap) / I am not allergic to latex. I do not have epilepsy or any nervous system problem. I have not had Guillian Barre syndrome. / VIS CDC
11/18/08
A D U / Tuberculosis Test / I have not had a positive TB test in the past, I do not currently have TB to my knowledge and I have not received a live vaccine in the last month.
A D U / Typhoid Live Oral / I do not have acute vomiting or diarrhea. I am not allergic to gelatin or gelatin-containing products / VIS CDC
05/19/04
A D U / Typhoid Typhim /

I am not allergic to phosphate buffers or phenol.

/

VIS CDC

0 5/19/04

A D U /

Yellow Fever

/ I am not allergic to eggs or egg products. I am not immunosuppressed.
I do not have a history of thymus disorder or dysfunction. / VIS CDC
03/30/11
A D U / Varicella / I am not allergic to neomycin, gelatin or gelatin-containing products, I am not immuno-suppressed, I have not received an antibody-containing blood product in the last 11 months. / VIS CDC
03/13/08

A=ACCEPTD=DECLINEU=UP-TO-DATE

I have been informed about the recommended vaccinations, possible side-effects, and contraindications, and have had the chance to ask questions. I understand the benefits and risks of the vaccination(s) and request that the following vaccines be given to me. My signature also indicates that the statement following the vaccine is true to the best of my knowledge.

Name: ______Signature: ______Date:______

06/2010 updated