Valley Health Care School Based Health Clinic Immunization Consent Form Step 1 of 3 33% DATE: - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY PATIENT DOB: - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY PATIENT NAME: * RequiredPATIENT AGE: * RequiredNAME OF PATIENT'S SCHOOL: * RequiredPATIENT GRADE: * RequiredI understand that by signing this form I am giving my consent for the immunizations marked below to be administered at the School Based Health Clinic. Any future vaccines indicated (vaccines that require more than one dose) will be administered at the time they are due. I have also been given an updated Vaccine Information Sheet for each vaccination and have had the opportunity to voice any questions or concerns prior to the administration of the vaccine.Parent/Guardian Signature * RequiredPhone Number * RequiredEmail * Required Special notes to Provider/Vaccinator you wish to convey: INSURANCE INFORMATIONDoes your child have Medicaid? * RequiredYesNoMedicaid ID #Does your child have CHIP? * RequiredYesNoCHP #If your child does not have health insurance, would you like to be contacted by a representative of a community organization or a WV State approved low-income health insurance plan? * RequiredYesNoDoes your child have other insurance? * RequiredYesNoName:Coverage Number:Policy Holder’s Last Name:Policy Holder’s First Name:Relationship to Patient:Date of Birth: - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY Place a check mark (√) in the following ❑ if you would like your child to receive the vaccination. Seasonal INFLUENZA TDAP** MCV 4** MEN B 1st MEN B 2nd HPV 9* 1st HPV 9* 2nd HPV 9* 3rd HEP A 1st HEP A 2nd * If series begun before 15th birthday; only 2 doses needed. **Required for Randolph County School entry for 7th and 12th graders. Why get vaccinated? ● TDAP and MCV4 (Meningitis A, C, Y, & W) vaccines are required by Randolph County Schools for admission into 7th and 12th grades. ● The MenB (Meningitis B), HPV (Human Papillomavirus), and Flu vaccines are recommended by healthcare providers but not required for school entry. Tdap Vaccine: protects against three diseases: tetanus, diphtheria, and pertussis (whooping cough). This vaccine can be safely given at the same time as the other vaccines listed. Meningococcal Vaccines: ● MCV4 Vaccine: protects against the four most common viruses (A, C, W, and Y) that cause meningitis (an infection of the lining of the brain and spinal cord) and infections of the blood.This vaccine can be safely given at the same time as the other vaccines listed. ● MenB Vaccine: protects against the meningitis B virus which isn’t as common in the U.S. as other meningitis viruses but the illness can develop more quickly and have worse side effects/outcomes than other the other meningitis viruses. This is a two dose vaccine series and the second MenB vaccine is given at least one month after the first MenB vaccine. This vaccine can be given at the same time as the other vaccines listed. HPV (Human Papillomavirus) Vaccine: protects against the human papillomavirus (HPV) types that are associated with many cancers, including: ● throat cancer in females and males ● anal cancer in females and males ● cervical cancer in females ● vaginal and vulvar cancers in females ● penile cancer in males ● genital warts in females and males The HPV Vaccine requires more than one vaccine to prevent infection of HPV. The number of HPV vaccines your child gets varies depending on your child’s age. The HPV vaccine is a series of two vaccines spaced six months apart in kids 9yo-14yo. After these two HPV vaccines your child will not need anymore HPV vaccines even after they turn 15yo or become an adult. If your child is over 15yo they will need three shots to complete the HPV series. The second shot will be scheduled two months after the first shot and the third shot will be scheduled six months after the first shot. After this three shot series is complete your child will not need anymore HPV vaccines even after they become an adult. This vaccine can be safely given at the same time as the other vaccines listed. Hepatitis A: is a serious liver disease. It is caused by the hepatitis A virus (HAV). HAV is spread from person to person through contact with the feces (stool) of people who are infected, which can easily happen if someone does not wash his or her hands properly. You can also get hepatitis A from food, water, or objects contaminated with HAV.