Tuberculin (TB) Skin Test

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Full Address

Street Address

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Please answer the following questions before receiving your TB skin test:

Have you ever had a positive skin test before?

Have you ever received the BCG vaccine?

Have you had any vaccinations in the last four weeks?

Were you born outside of the United States?

Are you taking any corticosteroid medication, such as prednisone?

Do you have any health condition, which may alter your immune system?

Have you recently experienced any of the following symptoms: persistent cough lasting up to three weeks or longer, weight loss, night sweats, bloody sputum, generalized fatigue, anorexia, or fever?

If you answered YES to any of the above questions, you may have a decreased ability to respond to the TB skin test. Please ask the nurse for more information.

Parrent/Guardian MUST accompany child under 18 years of age

I hereby give my consent to the Village of Arlington Heights to administer a TB skin test and release the Village of Arlington Heights from all rsponsibility for reactions that may occur from this test. I understand that I must return to have my TB skin test evaluated & documented.

Please bring cash or check in the amount of $15.00. Payments made by credit or debit card will incur a service fee of 3.75% of the transaction amount or a minimum fee of $2.50 per transaction, whichever is greater.

Sign Here (Parent/Guardian signature if under 18)

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I agree to electronically sign and create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

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