Polson Middle School Adolescent Vaccine Consent Form

Adolescent Vaccine Consent Form Polson Middle School

Please read the following carefully
Dear Parents and Guardians:

Administrative Rules of Montana (ARM 37.114.705) require that each child receive a Tdap shot prior to entering 7th grade. In order to faciliate the process, the Lake County Health Department is partnering with your child's school to offer Tetanus, Diphtheria, and acellular Pertussis (Tdap) vaccinations to the 6th graders at their school.

The health department is also offering Meningococcal (MCV4) and Human Papillomavirus vaccines (HPV/Gardasil 9) to all eligible students. The Advisory Council on Immunization Practices (ACIP) strongly recommends these vaccines for all adolescents.

The vaccine information statements (VIS) for each vaccine can be viewed here:
- Tdap
- MCV4
- HPV
If you would like your child to receive any of these vaccines at school on April 9, 2024, please complete AND sign the following consent form.
Personal Information
Person's Name to be Vaccinated*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Person getting vaccinated attends *
Race/Ethnicity: Please check ALL that apply.*

WhiteBlack/African AmericanAmerican Indian/Alaska NativeNative Hawaiian/Pacific IslanderAsianHispanicOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Vaccines to Be Administered: please check the vaccines you wish to be given to your child:*

	Yes	No
Tetanus, Diphtheria, Pertussis (Tdap)--REQUIRED
Human Papillomavirus (HPV)--RECOMMENDED
Meningococcal (MCV4)--RECOMMENDED

Insurance, Payment, and VFC Eligibility Screening

Please check appropriate box and complete requested information.
The person to be vaccinated has insurance or Healthy Montana Kids (CHIP). Lake County Health Department will bill the insurance company. Make no payment at this time but note that you may be responsible for the portion unpaid by your insurance. Please provide your insurance information:
Subscriber Name:
Subscriber DOB:

MonthDayYear
Date
Insurance Company:
Policy Number:
Group Number:
The person to be vaccinated is uninsured, is IHS/Tribal Health Eligible, OR has Medicaid (Healthy Montana Kids PLUS). If the patient is in one of these categories, they qualify for the Vaccines for Children (VFC) Program. There is a $21.00 fee per shot. Please make checks out to "Lake County Health Department". No child will be denied services due to the inability to pay. Sliding fee available (see income verification).
Name of covered person:
Date of Birth:
Medicaid #:
Income Verification

I would like to be considered for a discounted fee. Please complete next section:
Average Household (Monthly or Yearly) Income:
Number of people in the household:
Person Filling Out Form
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relation to Person Being Vaccinated*
By signing this form, I hereby accept that I have read and understood the acknowledgment letter provided above. I declare that the information I have provided above is correct.

I understand that my child's immunizations will be entered into the Montana Immunization Registry (imMTrax) and may be shared with medical providers and schools, as well as for administrative purposes under the confidentiality rules that are HIPAA compliant.

I give my consent for vaccination and record maintenance in imMTrax. I understand that I can revoke this authorization and have my child's record removed at any time by contacting my local health department.
Signature*

Clear
Date*

MonthDayYear

This Section For Health Department Use Only

Skip this section, but please hit "Submit" at the bottom of the page. Thank you!
Vaccine Stock (Circle One): VFC PVT

Clinic Location: ________________________________________________________

Vaccine Name/Mfg.________________ Lot#_________________Exp. ___________

Injection Site _________________ VIS_____

Vaccine Name/Mfg.________________ Lot#_________________Exp. ___________

Injection Site _________________ VIS_____

Vaccine Name/Mfg.________________ Lot#_________________Exp. ___________

Injection Site _________________ VIS_____

NOTES:

Administrator Signature: ________________________________ Date____________
Should be Empty:

	Yes	No	Don't know
Is the person to be vaccinated sick today?
Does the person to be vaccinated have allergies to medication, food, or a vaccine component, or latex?
Has the person to be vaccinated ever had a serious reaction after receiving a vaccination?
Does the person to be vaccinated 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? Is he/she on long-term aspirin therapy?
If the person to be vaccinated is 2 through 4 years of age, has a healthcare provider told you that the child had wheezing or asthma in the past 12 months?
If your person to be vaccinated is a baby, have you ever been told he or she has had intussusception?
Has the person to be vaccinated, their sibling, or their parent had a seizure; has the person to be vaccinated had brain or other nervous system problems?
Does the person to be vaccinated have cancer, leukemia, HIV/AIDS, or any other immune system problem?
Does the person to be vaccinated have a parent, brother, or sister with an immune system problem?
In the past 3 months, has the person to be vaccinated taken medications that affect the immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or had radiation treatments?
In the past year, has the person to be vaccinated received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
Is the person to be vaccinated pregnant or is there a chance they could become pregnant during the next month?
Has the person to be vaccinated received any vaccinations in the past 4 weeks?

Adolescent Vaccine Consent Form Polson Middle School

Personal Information

Medical History

Insurance, Payment, and VFC Eligibility Screening

Person Filling Out Form

This Section For Health Department Use Only