Tuberculin (TB) Skin Test

Tuberculin (TB) Skin Test
Full Name*

First NameLast Name
Age*
Birth Date:

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Full Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please answer the following questions before receiving your TB skin test:
Have you ever had a positive skin test before?*

YesNo
Have you ever received the BCG vaccine?

YesNo
Have you had any vaccinations in the last four weeks?*

YesNo
Were you born outside of the United States?*

YesNo
Are you taking any corticosteroid medication, such as prednisone?*

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

YesNo
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?*

YesNo
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.
Sign Here (Parent/Guardian signature if under 18) *

First NameLast Name
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.
Today's Date

MonthDayYear
Date
Signature
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Tuberculin (TB) Skin Test

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

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.