HPV Vaccine Consent form - Grey Bruce Health Unit

Consent for HPV Immunization
Student’s Name: Last ________________________First_____________________ Sex: male/female
Birth Date: ________________ School:_______________ Ontario Health Card #: _________________
year month day
Student’s Health History
Does the student:
Have any serious medical conditions?
Take over-the-counter or prescription medications?
Have allergies to yeast, aluminium, sodium chloride,
L-histidine, polysobate or sodium borate?
Have a history of reaction(s) to any immunizations?
Received HPV vaccine previously?
If yes, provide date(s) and name of vaccine
Are you feeling well today? (Ask on day of clinic.)
No
Yes
If Yes, Provide details
Date(s) administered:
Name of Vaccine:
YES.
I have read or had explained to me the information
about this vaccine. I understand the benefits, side
effects and risks. I consent for the student to receive
the three-dose series of HPV vaccine.
Parent/Guardian/Student Signature:
(in ink)
Date: _______________
Phone: Home:____________ Alt.#: ____________
NO.
I have read or had explained to me the information
about this vaccine. I understand the benefits, side
effects and risks. I DO NOT consent for the student to
receive the three-dose series of HPV vaccine.
Parent/Guardian/Student Signature:
(in ink)
Date: _____________
Phone: Home: ___________ Alt.#: ______________
FOR NURSE’S USE ONLY
GARDASIL ® 0.5mL IM
Dose Date and Time Site Lot # Nurses Signature
# 1 Right deltoid
Left deltoid
# 2 Right deltoid
Left deltoid
#3 Right deltoid
Left deltoid
Comments:
This information is being collected pursuant to the Health Protection and Promotion Act, R.S.O.1990, c.H.7 and will be retained, used, disclosed and disposed of in
accordance with the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c.M.56, the Personal Health Information Protection Act, 2004, S.O.c.3
and all applicable federal and provincial legislation and regulations governing the collection, retention, use, disclosure and disposal of information. Any questions regarding
this collection may be directed to the Director of Finance and Administration at 101 17 th Street East, Owen Sound, Ontario, N4K 0A5, (519)376-9420.
Revised July 2012