13057/JUL11 REV11-12
www.gov.ns.ca/dhw
For Public Health Use Only: to be completed by the Public Health Nurse
Vaccine Given:
Vaccine Trade Name:
1st Dose: Site: Route: Lot #
Date: Signature:
2nd Dose: Site: Route: Lot #
Date: Signature:
3rd Dose: Site: Route: Lot #
Date: Signature:
Print firmly with a ballpoint pen; you are making 3 copies.
V
accines
c
an prevent many communicable diseases. It is
recommended that you follow the immunization schedule
that you can get from your local Public Health Services Office.
You/your child is now due for the following vaccine:
Please read and detach the Important Information sheet.
It will tell you about the vaccine, the disease(s) it prevents,
and the benefits, risks and side effects.
If you have any questions, please call your local Public Health
Services office (see above) or your family doctor before you
sign and return all 3 copies of this Consent Form to the
Public Health Nurse
.
Do Not separate the 3 copies of this Consent Form. Please return all 3 copies to your school public health nurse. You will receive a copy after all vaccine(s) have been given.
Immunization Consent Form
Public Health Services
STUDENT’S PERSONAL INFORMATION to be completed by parent/guardian or student
Student’s Full Name: Parent/Guardian’s Name:
Address:
Postal Code:
Home Phone: Work or Alternate Phone: Doctor’s Name:
School Name: Teacher’s Name and Room Number:
HEALTH CARD NUMBER: Date of Birth: Sex:
Year Month Day MF
Has this student ever had a serious reaction to a vaccine? Yes
No
If yes, explain
I have read the information sheet provided and understand the benefits, risks and side effects of the vaccine to be given.
Check (✓) one.
YES
I CONSENT
to the vaccine now due.
NO
I DO NOT CONSENT
If already vaccinated with the vaccine listed above, provide: Date:
Signature: Date:
(Parent/Guardian or Student)
-
-
Copy distribution: GREEN – PHS; YELLOW – Family Doctor; PINK – Parent/Guardian or Student
(Vaccine) (# of Doses Required)
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