Back-to-School Vaccine Consent

Back-to-School Vaccine Consent

Service provided by the Putnam County Health Department.
Child Information
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Parent/Guardian Name*

First NameLast Name
Phone Number*
Address*

Street Address

Street Address 2

CityState

Zip Code
Insurance
Please select one of the below.*

My child has MO HealthNet or insurance provided through the State of MO.My child has privately paid health insurance through the Marketplace, work, etc.My child has no health insurance.My child is a American Indian/Alaskan Native.
Please attach a photo of the front and back of insurance card.

Cancelof
Health History

Vaccine Screening*

	Yes	No	If Yes, Please Explain
Is your child sick today?
Does your child have any food or medication allergies?
Does your child have a history of fainting or seizures?
Does your child have a serious medical condition?
Has your child ever been diagnosed with Guillain-Barre Syndrome?
Is your child pregnant?
Is your child currently on antibiotics or antiviral medications (example: Amoxicillin, Tamiflu, Bactrim, etc.)

Do you have any questions/concerns regarding vaccines that you would like for a nurse to contact you about?*

Yes, I have questions/concerns. Please contact me.No, I have no questions/concerns.
Vaccine Selection

To be administered on Wednesday, March 20, 2024
I give permission for my child to have the following vaccines:*

Tdap (Tetanus required prior to start of 8th grade)HPV (Recommended for students ages 9 and older)Meningococcal B (Recommended for 11th grade students)Meningococcal (Required prior to the start of 8th & 12th grade)
Vaccine Information Statements

Tdap - Click here to read the VIS.
HPV - Click here to read the VIS.
Meningococcal B - Click here to read the VIS.
Meningococcal - Click here to read the VIS.
HIPAA Compliance
Click the link below to read the full disclosure of HIPAA.
Acknowledgment of HIPAA Compliance*

I acknowledge by my initials, that I have been offered a copy of Putnam County Health Department’s “Notice of Privacy Practice Act (HIPAA)”. I understand that if my child has Medicaid, insurance will be billed for vaccine and injection.
Consent
Consent For Immunization*

Yes, please vaccinate my child with the vaccines I have indicated above. I have read or been provided with the opportunity to read the associated Vaccine Information Statement for the vaccine indicated above. I have had the opportunity to ask questions. I understand the benefits and risks of the vaccine requested and ask that the vaccine for which I have signed below, be given to the person indicated above. I am authorized by RSMo 431.058 to make this request.
Parent/Guardian Signature*

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Back-to-School Vaccine Consent

Child Information

Insurance

Health History

Vaccine Selection

HIPAA Compliance

Consent