"Shingles Vaccine Administration Consent Form"

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Download "Shingles Vaccine Administration Consent Form"

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Shingles Vaccine Administration Consent Form
I have been given the opportunity to ask questions about the vaccine listed below and my questions
were answered to my satisfaction. I have received the appropriate CDC Vaccine Information
Statement (VIS) and have read the information or had it read to me. I have received all the
information I need to give this informed consent. I have never had a history of hypersensitivity or a
life threatening allergic reaction to gelatin, neomycin or to any other component of the vaccine. I
understand any individual age 60 or older should receive this vaccine.
I understand the benefits, risks and contraindications to this vaccine. I understand, as with all medical
treatments, there is no guarantee that I will become immune. I am not immunosuppressed, on
hemodialysis, breastfeeding, or pregnant. I am not taking high dose corticosteroids or other
immunosuppressive therapy. I do not have active tuberculosis. I will inform my health care provider
if I have any current illness, infection or elevated temperature. I understand I may need to postpone
the vaccination until I have recovered. I will inform my health care provider if I have received a
vaccine or injection recently.
I understand that vaccines, like any medication, can cause mild side effects including
soreness/redness at the injection site, fever, headache and body aches. Other reported side effects
include bruising, itching at the injection site, diarrhea, runny nose, or rash. I understand that
vaccines can in rare instances cause complications, including infection, allergic reaction and death. I
also, understand that the chance of serious harm is very rare and that these vaccinations are FDA
approved. I agree to accept this risk to decrease my chances of contracting a serious preventable
disease. I understand to seek medical attention immediately if I have any difficulty breathing,
swelling of the lips, wheezing, hoarseness, fast heart beat, hives, dizziness or swelling of the throat.
Vaccine to be administered:
Shingles (VIS 9/11/06
)
_____________________________________________________________
____________________
____________
Name of Patient (Please Print Clearly)
Date of Birth
AGE
_____________________________________________________________________________________________________
Signature of Patient
Date
_________________________________________________________________________________
Signature of Parent/Legal Guardian
Date
PHARMACY
Please do not write below this line.
Authorized personnel only
Dose 0.65 ml subcutaneous
Zostavax
_________
____________ ______________
_______
SC
______
Age 60+
Date
Manufacturer
Lot#, exp date
Injection Site
Route Initials
Shingles Vaccine Administration Consent Form
I have been given the opportunity to ask questions about the vaccine listed below and my questions
were answered to my satisfaction. I have received the appropriate CDC Vaccine Information
Statement (VIS) and have read the information or had it read to me. I have received all the
information I need to give this informed consent. I have never had a history of hypersensitivity or a
life threatening allergic reaction to gelatin, neomycin or to any other component of the vaccine. I
understand any individual age 60 or older should receive this vaccine.
I understand the benefits, risks and contraindications to this vaccine. I understand, as with all medical
treatments, there is no guarantee that I will become immune. I am not immunosuppressed, on
hemodialysis, breastfeeding, or pregnant. I am not taking high dose corticosteroids or other
immunosuppressive therapy. I do not have active tuberculosis. I will inform my health care provider
if I have any current illness, infection or elevated temperature. I understand I may need to postpone
the vaccination until I have recovered. I will inform my health care provider if I have received a
vaccine or injection recently.
I understand that vaccines, like any medication, can cause mild side effects including
soreness/redness at the injection site, fever, headache and body aches. Other reported side effects
include bruising, itching at the injection site, diarrhea, runny nose, or rash. I understand that
vaccines can in rare instances cause complications, including infection, allergic reaction and death. I
also, understand that the chance of serious harm is very rare and that these vaccinations are FDA
approved. I agree to accept this risk to decrease my chances of contracting a serious preventable
disease. I understand to seek medical attention immediately if I have any difficulty breathing,
swelling of the lips, wheezing, hoarseness, fast heart beat, hives, dizziness or swelling of the throat.
Vaccine to be administered:
Shingles (VIS 9/11/06
)
_____________________________________________________________
____________________
____________
Name of Patient (Please Print Clearly)
Date of Birth
AGE
_____________________________________________________________________________________________________
Signature of Patient
Date
_________________________________________________________________________________
Signature of Parent/Legal Guardian
Date
PHARMACY
Please do not write below this line.
Authorized personnel only
Dose 0.65 ml subcutaneous
Zostavax
_________
____________ ______________
_______
SC
______
Age 60+
Date
Manufacturer
Lot#, exp date
Injection Site
Route Initials