CONSENT I have read or have had explained to me the above information and received a copy of the Vaccine Information Statement and understand Spokane Regional Health District’s (SRHD) Privacy Policy. I have had a chance to ask questions, which were answered to my satisfaction. I consent to inclusion of this data in the Washington State Immunization Information (IIS) Registry. I believe I understand the benefits and risks of the vaccines checked below and request that the vaccine be given to me or the person named above for whom I am authorized to make this request. Also, by signing this consent, I am allowing myself to be filmed or photographed during the immunization clinic today. DTAP DTAP/IPV MMR/V (6 AND (4-6 HEP A HEP B (12 AND HIB HPV9 MCV4 MMR YOUNGER) YEARS YOUNGER) ONLY) TDAP PCV-13 POLIO (7 AND CHICKENPOX VIS DISTRIBUTED OLDER) (VARICELLA) ADULTS HEP B HEP A/B MMR PCV-13 TDAP SHINGLES VIS DISTRIBUTED _________ SIGNATURE OF PATIENT PARENT CAREGIVER (Check one) DATE □ □ □ CLINIC USE ONLY VACCINE ADMINISTRATION RECORD VACCINE VIS MANUFACTURER /LOT # / EXP DATE INJECTION SITE Route LA RA IM DTAP 5/17/07 □ □ □ LA RA IM DTAP/IPV 5/17/07 □ □ □ 7/20/16 LA RA IM HEP A 7/20/16 □ □ □ LA RA IM HEP B 7/20/16 □ □ □ LA RA IM HEP A/B 7/20/16 □ □ □ LA RA IM HPV9 12/2/16 □ □ □ LA RA IM MCV4 3/31/16 □ □ □ LA RA SC MMR 4/20/12 □ □ □ LA RA SC MMR/V 5/21/10 □ □ □ LA RA IM PCV-13 11/5/15 □ □ □ LA RA IM 7/20/16 □ □ □ LA RA IM PPSV23 4/24/15 □ □ □ LA RA SC SHINGLES 10/6/09 □ □ □ LA RA IM TDAP 2/24/15 □ □ □
CONSENT I have read or have had explained to me the above information and received a copy of the Vaccine Information Statement and understand Spokane Regional Health District’s (SRHD) Privacy Policy. I have had a chance to ask questions, which were answered to my satisfaction. I consent to inclusion of this data in the Washington State Immunization Information (IIS) Registry. I believe I understand the benefits and risks of the vaccines checked below and request that the vaccine be given to me or the person named above for whom I am authorized to make this request. Also, by signing this consent, I am allowing myself to be filmed or photographed during the immunization clinic today. DTAP (6 AND YOUNGER) DTAP/IPV (4-6 YEARS ONLY) HEP A HEP B HIB HPV9 MCV4 MMR MMR/V (12 AND YOUNGER) PCV-13 POLIO TDAP (7 AND OLDER) CHICKENPOX (VARICELLA) VIS DISTRIBUTED ADULTS HEP A/B HEP B MMR PCV-13 TDAP SHINGLES VIS DISTRIBUTED _________ SIGNATURE OF □ PATIENT □ PARENT □ CAREGIVER (Check one) DATE CLINIC USE ONLY VACCINE ADMINISTRATION RECORD VACCINE VIS MANUFACTURER /LOT # / EXP DATE INJECTION SITE Route DTAP 5/17/07 □ LA □ RA □ IM DTAP/IPV 5/17/07 7/20/16 □ LA □ RA □ IM HEP A 7/20/16 □ LA □ RA □ IM HEP B 7/20/16 □ LA □ RA □ IM HEP A/B 7/20/16 □ LA □ RA □ IM HPV9 12/2/16 □ LA □ RA □ IM MCV4 3/31/16 □ LA □ RA □ IM MMR 4/20/12 □ LA □ RA □ SC MMR/V 5/21/10 □ LA □ RA □ SC PCV-13 11/5/15 □ LA □ RA □ IM 7/20/16 □ LA □ RA □ IM PPSV23 4/24/15 □ LA □ RA □ IM SHINGLES 10/6/09 □ LA □ RA □ SC TDAP 2/24/15 □ LA □ RA □ IM
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