Recombinant-Zoster-Shingles-Vaccine-Informed-Consent

Recombinant Zoster (Shingles) Vaccine Informed Consent

Section 1: Information about person to receive vaccine (please print)

NAME (Last)

(First)

(M.I.)

DATE OF BIRTH

month________ day______ year ______

Section 2: Screening for Vaccine Eligibility

The following questions will help us to know if you can get the recombinant zoster (shingles) vaccine.

Please mark YES or NO for each question.	YES	NO
1. Do you have a history of severe allergic reaction, such as anaphylaxis, to any component of the recombinant zoster (shingles) vaccine or any severe, life-threatening allergies? If yes, list the allergy(ies) and the reaction to them: __________________________________________________________	⁭	⁭
2. Are you experiencing an acute episode of herpes zoster? (If yes, then delay vaccination until the acute stage of the illness is over and symptoms abate.)	⁭	⁭

Section 3: Consent

CONSENT FOR VACCINATION:

I have read or had explained to me the current Vaccine Information Statement for the recombinant zoster (shingles) vaccine and understand the risks and benefits.

⁭ I, ______________________________(resident or representative) GIVE CONSENT for ________________________________(resident’s name) to receive the recombinant zoster (shingles) vaccine.

⁭ I, _______________________________(resident or representative) DO NOT GIVE CONSENT for ________________________________(resident’s name) to receive the recombinant zoster (shingles) vaccine due to _______________________________________________________________________.

Signature: _______________________________________________ Date: ___________________

(Resident or Resident Representative)