Fillable Printable Shingles Vaccine Administration Consent Form

Shingles Vaccine Administration Consent Form

I have been given the opportunity to ask questions about the vaccine listed below and my questions

were answered to my satisfaction. I have received the appropriate CDC Vaccine Information

Statement (VIS) and have read the information or had it read to me. I have received all the

information I need to give this informed consent. I have never had a history of hypersensitivity or a

life threatening allergic reaction to gelatin, neomycin or to any other component of the vaccine. I

understand any individual age 60 or older should receive this vaccine.

I understand the benefits, risks and contraindications to this vaccine. I understand, as with all medical

treatments, there is no guarantee that I will become immune. I am not immunosuppressed, on

hemodialysis, breastfeeding, or pregnant. I am not taking high dose corticosteroids or other

immunosuppressive therapy. I do not have active tuberculosis. I will inform my health care provider

if I have any current illness, infection or elevated temperature. I understand I may need to postpone

the vaccination until I have recovered. I will inform my health care provider if I have received a

vaccine or injection recently.

I understand that vaccines, like any medication, can cause mild side effects including

soreness/redness at the injection site, fever, headache and body aches. Other reported side effects

include bruising, itching at the injection site, diarrhea, runny nose, or rash. I understand that

vaccines can in rare instances cause complications, including infection, allergic reaction and death. I

also, understand that the chance of serious harm is very rare and that these vaccinations are FDA

approved. I agree to accept this risk to decrease my chances of contracting a serious preventable

disease. I understand to seek medical attention immediately if I have any difficulty breathing,

swelling of the lips, wheezing, hoarseness, fast heart beat, hives, dizziness or swelling of the throat.

Vaccine to be administered: Shingles (VIS 9/11/06 )

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Name of Patient (Please Print Clearly) Date of Birth AGE

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Signature of Patient Date

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Signature of Parent/Legal Guardian Date

Please do not write below this line. PHARMACY Authorized personnel only

Dose 0.65 ml subcutaneous

Zostavax _________ ____________ ______________ _______ SC ______

Age 60+ Date Manufacturer Lot#, exp date Injection Site Route Initials