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What You Should Know Before You Sign Up to Take the Rabies ...

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<strong>Rabies</strong> Pre-Exposure Immunization Consent FormCheck appropriate box: Year I Year II Year III Year IV Vet Student Graduate Student Student Worker Faculty Staff Acct. # (for employees only) _________________Check one: I have never had a rabies vaccination and am taking <strong>the</strong> full three-dose pre-exposure series I have already had <strong>the</strong> pre-exposure series and am taking one booster dosePlease print <strong>the</strong> following information:Name: _____________________________________________ Sex: ________ Age: ________SSN: _____________________________________ Date of birth: ____________________________Department or Box #: ____________________Are you allergic <strong>to</strong> any of <strong>the</strong> following substances?Eggs No YesBovine gelatin No YesChicken No YesHave you ever had an adverse reaction <strong>to</strong> any vaccine?NeomycinChlortetracyclineAmphotericin B No Yes No Yes No Yes No YesIf yes, give details: __________________________________________________________________Are you currently being treated with any type of corticosteroid or any o<strong>the</strong>r immunosuppressive drugs? No Yes (specify): _____________________________________________________________If female, are you pregnant? No Yes (due date): _____________________________________I have read <strong>the</strong> information regarding <strong>the</strong> possible side effects and complications of RabAvert <strong>Rabies</strong> Vaccinefor Human Use. I consent <strong>to</strong> having <strong>the</strong> primary vaccination series administered <strong>to</strong> me.Date: _______________<strong>Sign</strong>ature: __________________________________________________SHC Use OnlyDate Lot # Site InitialsMake checks payable <strong>to</strong> “LSU SVM.”Bring this completed form with you <strong>to</strong> orientation.Rev. June 2003

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