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Human papilloma virus (HPV) vaccination consent form

School Age Immunisations Team

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Human Papilloma Virus (HPV) Consent Form

Student First Name:

 

 

Student Surname: Ethnicity: Date of Birth:
Home Address:

 

 

Postcode:

Daytime contact telephone number

1.

 

2.

School and year group:

 

 

GP/doctor’s surgery:

Please COMPLETE and SIGN the relevant consent box below. Must be completed by parent or legal guardian only.

Consent for both HPV immunisations (Year 8 and Year 9) (Please complete one box only)
YES, I give consent for my child to be immunised against Human Papillomavirus and have discussed this with them.

 

I confirm I have parental responsibility to consent to the Human Papillomavirus immunisation.

 

Signed…………………………..Date…………………..

 

Print name ……………………………………………….

 

Relationship to child ……………………………………

 

NO, I do not give consent for my child to be immunised against Human Papillomavirus and have discussed this with them.

 

If, after discussion you and your child decide that you do not want them to have the vaccine, please give the reason below.

 

………………………………………………………………………..

 

Signed…………………………..       Date………………………..

 

Print name ………………………………………………………….

 

Relationship to child ……………………………………………….

Please complete the important health questions below:

  Yes (please give details) No
Does your child have any medical problems?    
Is your child taking any regular medication?  
Does your child have any severe allergies?    
Has your child ever had a reaction to previous vaccinations?    
Has your child received the HPV vaccination previously?    

 For Office Use:

Vaccine Date/Time Site of 0.5ml IM injection Batch No/Expiry Signature Print name
HPV 1

Gardasil

L Delt R Delt
HPV 2

Gardasil

L Delt R Delt

Thank you for completing this form, please return completed to school immediately. All forms must be returned.

Privacy statement

This service is provided by Sirona care & health, as part of the Community Children’s Health Partnership (CCHP).

Keeping your personal information safe and secure is important to us – so we’ve updated our privacy notice to reflect the changes in data protection laws.

If you have any queries about how your personal information is used or your rights, please contact our Data Protection Officer:

Email:

Telephone:

Post:

sirona.dataprotectionofficer@nhs.net

0300 124 5403

Data Protection Officer, Sirona care & health,  2nd Floor, Kingswood Civic Centre, High Street, Kingswood, Bristol, BS15 9TR

For office use only:

Immunisation checklist 1st DOSE 2nd DOSE
YES NO YES NO
Details correct on consent form/consent given?
Well today?
Any medical problems?
Any medication/treatment?
Any known allergies?
Any reactions to previous vaccinations?
Any possibility of pregnancy?
Checked on CHIS list?
Advice on possible side effects and their management?
Advice sheet given?

 

Pupil consent: The immunisation checklist has been discussed with me and I consent to this immunisation.
HPV 1 Pupil Signature and date:

 

 

HPV 2 Pupil Signature and date: