Immunization Requirements for Dental Hygiene
Program At Texas Woman’s University
Revised Summer 2019
Immunization Compliance Inquiries to:
Immunization Program Phone: (940) 898-3825
P.O. Box 425467 (888) 898-8825
Denton, TX 76204-5467
https://patient-twu.medicatconnect.com/
Name: Student ID:
Date of Birth: / / Phone #: ( )
Email Address: @ Alt. Phone #: ( )
Current Address:
Address City/State Zip
Sex (Male/Female): _______________________
IMPORTANT: SUBMISSION OF REQUIRED IMMUNIZATION RECORDS IS NECESSARY TO COMPLY WITH
TEXAS ADMINISTRATIVE CODE TITLE 25, P1, CH97, SUBCH B, RULE §97.61 AND THE POLICY OF TEXAS
PROOF OF THE FOLLOWING IMMUNIZATIONS IS REQUIRED PRIOR TO CLINICALS
All Vaccine/Immunization records must include full dates i.e. month/day/year & health care providers’ signatures. Health care provider
initials may be considered sufficient if the document is on a health care provider’s letterhead including the name & address of the practice.
School records which merely reflect dates of administration will NOT be accepted. Immunization records submitted without thorough
documentation will not be accepted at any clinical site and students will be required to repeat vaccines or obtain titers in lieu of vaccines if
applicable. All immunization records should be uploaded to TWU Student Health Patient Portal at https://patient-twu.medicatconnect.com/
Tdap – Tetanus, Diphtheria and Pertussis must be renewed every 10 years.
Flu – must be current Flu season (September –April) due annually. Record must include: Manufacturer, Flu
Lot number, expiration date, injection site and provider’s signature. Receipts are NOT accepted.
TB Screening – within past one year. TB Blood Testing required for all Dental Hygiene students (T-Spot
or Quantiferon Gold). After a current positive TB Blood Test, you must have a current Chest X-Ray and TB
Clearance Statement uploaded to the system.
MMR 2 doses OR Positive Titer – Measles, Mumps & Rubella Titer (must submit lab report).
Varicella 2 doses OR Positive Titer – must submit lab report for Titers. History of chicken pox not
accepted.
Hepatitis B Series (3 doses) - dose 2 (30) days after dose 1, dose 3 (5 months) after dose 2.
Hepatitis B Titer (Hepatitis B Surface Antibody) – 30 days after completion of Hepatitis B Series (in lieu of
Hepatitis B Series completion).
**Please note negative titer results may require a repeat of vaccine doses and additional titer
screening.
Student must sign for immunization compliance:
I certify that, to the best of my knowledge, the above information and attached copies are true and correct.
I also give my consent for the release of my immunization records to faculty/staff at Texas Woman’s University. I further consent
to the release of my immunization records to any clinical facility that I request they be sent to for clinical rotations
or employment.
Student Signature Date Signed
In accordance with Leg. House Bill 1922, an individual is entitled to request to be informed about the information collected about them; receive and review their
information; and correct any incorrect information. Disclosure of your social security number is required in order to set up your immunization status at Texas Woman’s
University. Your social security number will be used as a unique number to identify you. Any further disclosure of your social security number will be governed by
the Public Information Act (Chp 552 of the Texas Government Code).
