Free DEPARTMENT OF HEALTH & FAMILY SERVICES - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-00051 (3/09)

STATE OF WISCONSIN Wis. Stats. 252.04

Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) Information collected on this form will be used to document authorization for receipt of Tdap, varicella and/or MCV4 vaccine(s) at your child's school. Information may be shared through the Wisconsin Immunization Registry (WIR) with other health care providers directly involved with your child to assure completion of the vaccine schedule. My signature below authorizes Tdap (Tetanus, diphtheria, acellular pertussis) vaccine [Required (1 dose)] my child to receive these Varicella (Chickenpox) vaccine [Required (2 doses)] vaccine(s): MCV4 (Meningococcal conjugate) vaccine [Recommended (1 dose)] Check all that apply: Patient's Name (Last, First, Middle Initial) Address Home Telephone Number ( ) Race (Check one) African American American Indian or Alaskan Native White Other Asian Native Hawaiian / Pacific P. O. Box Mother's Maiden Name (Last, First, Middle Initial) City County Gender Male Female Ethnicity (Check one) Hispanic or Latino Non-Hispanic or Latino State Zip Code

Date of Birth (mm/dd/yyyy)

Eligibility Status - This section must be completed. (Check all that apply) Native American Medicaid Eligible Name of Physician BadgerCare Plus No Health Insurance Name of School Insured, Vaccines Covered Insured, Vaccines Not Covered Grade Relationship to Patient

Name of Parent or Guardian Responsible for Patient (Last, First, Middle Initial) Okay to share immunization data with Wisconsin Immunization Registry (WIR)? Yes No

I have been given a copy and have read, or have had explained to me, information about the disease(s) and vaccine(s) to be received. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) requested and ask that the vaccine(s) be given to me or to the person named above for whom I am authorized to make this request. Wisconsin Medicaid restricts billing recipients for any covered service(s). I understand that if I am a Medicaid / BadgerCare recipient I cannot be charged an administration fee or asked for any type of donation for the administration of any vaccine that is being provided. SIGNATURE - Person to receive vaccine or person authorized to sign on the patient's behalf. X
FOR OFFICE USE Tdap: route= IM site (circle one) RD or LD dose number= 1 Manufacturer________________________________________________________ Lot No. _____________________ Varicella: route= SQ site (circle one) RD or LD dose (circle one) 1 or 2 Manufacturer _______________________________________________________ Lot No.______________________ MCV4: route= IM site (circle one) RD or LD dose number= 1 Manufacturer _______________________________________________________ Lot No.______________________ VIS date: 11/18/08 VIS date: 03/01/08 VIS date: 01/28/08

Date Signed

Signature and title of person administering vaccine:_______________________________________________ Date vaccine administered: _______ LHD clinic address:______________________________________________________________________________________________________