RSV Vaccine Consent Form for Pregnant People

Name*

First NameLast Name

Date of Birth*

Date

Age*

Phone Number*

Please enter a valid phone number.

Do you have commercial insurance (through an employer)? (I understand that if my insurance is different than my child, I must provide a copy of my insurance at the time of vaccine administration)*

YesNo (Must provide at time of visit)

Full name of child at the practice (if applicable).

The following questions will help us determine if there is any reason you should not get the Abrysvo, RSV vaccine today. If you answer "yes" to any question, it does not necessarily mean your child should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider.

1. Are you feeling sick today?*

YesNoUnsure

2. Have you ever received a dose of the RSV vaccine?*

YesNoUnsure

3. Have you ever had an allergic reaction to any of the following? (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing.)*

	Yes	No	Unsure
A component of the Abrysvo vaccine?

4. I am confirming that I am 32-36 weeks pregnant.*

YesNoUnsure

5. I am accepting the mildly increased risk of preterm labor and pre-eclampsia. While the vaccine is approved to give between 32-36 weeks gestation, Tosa Pediatrics recommends administration after 34 weeks given fetal development*

YesNo

I have read or had explained to me the information contained at www.abrysvo.com and the CDC guidelines for Pregnant People (https://www.cdc.gov/vaccines/vpd/rsv/public/pregnancy.html) for the Abrysvo vaccine and understand the risks and benefits of the vaccine. I have had a chance to ask questions which have been answered to my satisfaction and understand the benefits and risks of the vaccine. I, on behalf of myself, my heirs, executors, and personal representatives hereby agree to release, indemnify, and hold harmless Tosa Pediatrics, its subsidiaries, affiliates, agents, owners, providers, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine.

I acknowledge disclosure of this vaccination to public health officials and other health care professionals. I understand this vaccine will be recorded in the Wisconsin Immunization Registry (WIR) for the purposes of sharing vaccination information with other health care providers and tracking vaccine inventory only.

In the event of an emergency situation, emergency medication (Epinephrine/Benadryl) and/or oxygen may be administered to me. In the event of an emergency situation, I authorize Tosa Pediatrics’ staff to obtain any necessary medical care they deem necessary including but not limited to, obtaining paramedic assistance and transport to a local hospital for additional treatment or observation.

Signature*

Date*

Date

RSV Vaccine for Pregnant People Consent Form