VACCINE CONSENT FORM Human Papillomavirus (HPV) Instructions: 1) 2) 3) 4) Read the HPV and Gardasil: Get the Facts information sheet. You may keep the fact sheet at home. Complete and sign the pink HPV Vaccine Consent Form in pen. Check your child’s name and date of birth. If wrong, please correct. Return the signed pink HPV Vaccine Consent Form to Ottawa Public Health as soon as possible in the prepaid envelope (if available) or fax the form to 613-580-9660 attn: School Immunization Clinics. 5) For more information contact Ottawa Public Health at 613-580-6744. Student’s Last Name Student’s First Name Ontario Health Card No. (optional) Date of Birth Gender (circle) M F School Name (For Grade 8) Parent/Guardian Name(First and Last Name) Home Telephone No. XXX-XXX-XXXX Class (e.g. 8-3, or 8-H) Daytime Phone No. XXX-XXX-XXXX Daytime Phone No. XXX-XXX-XXXX Parent/Guardian Name (First and Last Name) Vaccine Consent – Human Papillomavirus (HPV) Vaccine 3 doses - Gardasil ® YES, I want to get the HPV vaccine (Gardasil®). Please check one of the boxes below:  I have NOT been vaccinated with a previous dose of HPV vaccine  I have already been vaccinated with the following HPV vaccine(s): ( name if known):____________ st DATE of 1 DOSE: DD / MM / YY nd DATE of 2 DOSE: DD / MM / YY rd DATE of 3 DOSE : DD / MM / YYY I consent to be given the HPV vaccine. This consent is valid for up to 24 months, which includes the time required to get all three doses of the vaccine. I have read the HPV fact sheet provided, or have had the information about the HPV vaccine explained to me. I understand the possible side effects of the vaccine as well as the benefits. I understand that I can withdraw my consent at anytime in writing. Parent/Guardian Signature Student Signature (Print Name) Date : DD / MM / YY (Print Name) Date : DD / MM / YY NO, I do not want my child to get the HPV vaccine at this time. Please note: publicly funded HPV vaccine is only released to physicians for special health reasons. HPV vaccine at a doctor’s office may cost over $420 for 3 doses. Parent/Guardian Signature: (Print Name) Date : DD / MM / YY Personal Health Information is collected under the authority of the Health Protection and Promotion Act and will be used to administer vaccines including maintaining an immunization record for the vaccines. Questions regarding this collection and use of personal health information may be directed to the Supervisor, Vaccine Preventable Diseases, Ottawa Public Health by mail at 100 Constellation Drive, Ottawa, ON K2G 6J8, by telephone at 613-580-6744, or by e-mail at [email protected] or visit the Information Practice Statement of the Medical Officer of Health at: http://ottawa.ca/en/city-hall/your-city-government/policies-and-administrativestructure/information-practice-statement 06/2014 ottawa.ca/health | ottawa.ca/santé TEL/TÉL : 613-580-6744 | TTY/ATS : 613-580-9656