VACCINE CONSENT FORM

Personal Information

IF YOUR SCHOOL'S CLINIC IS WITHIN THE NEXT 2 SCHOOL DAYS, YOUR
REGISTRATION MAY NOT BE REVIEWED IN TIME. YOUR TEEN WILL BE SCHEDULED
FOR THE NEXT CLINIC. 
Gender: *

Health Insurance Information

Medical Screening for Vaccine Eligibility

1. Does the patient have allergies to medications, food, or any vaccine? *
 
2. Has the patient ever had a serious reaction to a vaccine? *
 
3. In the past three months, has the patient taken medications for the treatment of rheumatoid arthritis, Crohn's disease, or Psoriasis? *
4. Has the patient, a sibling, or a parent ever had a seizure or brain problem? *
5. Does the patient have cancer, leukemia, HIV/AIDS, or any other immune system condition? *
6. In the past three months, has the patient taken cortisone, prednisone, steroids or anti-cancer drugs or has had radiation treatment? *
7. Has the patient received a blood transfusion, blood products, or immune (gamma) globulin in the past year? *
8. Has the patient received any vaccinations in the past four weeks or taken an antiviral drug? *
 
9. Does the patient have a long-term health problem with lung, heart, kidney or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak? *
10. Is the patient on long-term aspirin therapy? *
11. Does the patient have a parent, brother, or sister with an immune system problem? *

Consent for Vaccination in the School Setting

I have viewed the Vaccine Information Statement(s) for the vaccine(s) requested, using the link below, or received a printed copy to review. I understand the benefits and risks of the vaccine(s) requested. I understand that a record of vaccinations administered in this program will be submitted to the statewide database, RICAIR within 48 hours of vaccination. I hereby release The Wellness Company from any and all liability associated with the administration and potential side effects of the vaccine.
 
In accordance with RIGL 23-4, 6-1 students age 16 or older may consent to routine, emergency, medical or surgical care. A minor parent may consent to treatment of their child.
 I would like my child to receive this vaccine
Hepatitis A (2 doses)
Hepatitis B (3 doses)
HPV - Gardasil (Human Papillomavirus- 2-3 doses)
MMR (Measles, Mumps & Rubella - 2 doses)
Meningitis A, C, W, Y (1-2 doses, required)
Polio (3-4 doses)
Tdap (Tetanus, Diphtheria, Pertussis)/Td
Serogroup B Meningococcal (2 doses recommended for college)
Varicella - Chicken Pox (2 doses)
The vaccine(s) checked should be given to the student named for whom I am authorized to make this request. I understand that all doses indicated for each vaccine are needed to receive full protection. Signature for a vaccine provides consent to receive all doses needed for that vaccine.


Please sign using your stylus, finger, or mouse. *
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