Immunization & Injection Clinic Immunization & Injection Clinic 1 Acknowledgement2 Personal Information3 Regular Immunizations & Vaccines4 High Risk Vaccines5 Health Conditions6 Consent ConsentBy checking “I agree” I am stating that I have read through this document and I agree to all of the terms stated below. I understand the reason and procedure regarding the administration of this/these immunization(s) and/or injection(s) have asked all outlying questions pertaining to the procedure. I understand that all of my personal health information will be protected and stored in a secure location. I also understand that this information will not be shared with any one unless medically necessary (i.e. positive tb skin test result). I understand that I have the right to withdraw my consent at any time without fear of being denied service in the future. *there is a $20.00 injection fee associated with the administration of all immunizations/injections that is to be paid prior to the injection* I Agree I Do Not Agree Signature* First Last (Of patient or Legal Decision-Maker)Date* Date Format: MM slash DD slash YYYY Confirmation* I have read and acknowledged the above Name* First Middle Last Date of Birth* Date Format: MM slash DD slash YYYY Gender*MaleFemalePrefer Not to DiscloseOtherAddress* Street Address Apt # City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email Preferred Daytime Phone*Home PhoneCell PhoneFamily Doctor* Yes No Physician's NameDo you have a Health Card?* Yes No OHIP Number*Version Code*Expiry Date* Date Format: MM slash DD slash YYYY Emergency Contact First Last Emergency Contact RelationshipEmergency Contact Phone TB Skin TestingTuberculin Purified Protein Derivative (5TU) Eligibility. Select option if applicable.Select One If ApplicableStudentContact with recent exposure to a known or suspected TB casePersons with HIV infectionHomeless individualsPersons entering rehabilitation or detox servicesEntry into long-term care for residents <65 years of ageTests deemed to be reasonably necessaryVaccines & DiluentsRow StartPertussis, Diphtheria, Tetanus, Polio and HIB VaccineEligibility: 5 or 6 years of age and unimmunized or require dose(s) to complete their primary series Haemophilus influenze type b VaccineCheck if applicable: Yes No Polio VaccineCheck if applicable: Yes No Meningococcal C Conjugate Vaccine (Meningitis)Check if applicable: Yes No Measles, Mumps and Rubella Vaccine (MMR)Check if applicable: Yes No Measles, Mumps, Rubella, and Varicella Vaccine (MMRV)Check if applicable: Yes No Pneumococcal Conjugate Vaccine (Pneumonia)Check if applicable: Yes No Column BreakPneumococcal Polysaccharide Vaccine (Pneumonia)Check if applicable: Yes No Rotavirus VaccineCheck if applicable: Yes No Tetanus and Diphtheria VaccineCheck if applicable: Yes No Tetanus, Diphtheria and Pertussis VaccineCheck if applicable: Yes No Varicella VaccineCheck if applicable: Yes No Herpes ZosterCheck if applicable: Yes No OtherPlease identify below of another vaccine or immunization that you need:Row End High Risk VaccinesBelow is a list of available High Risk Vaccines. If you are eligible please select your eligibility for the vaccine. If you are not looking for the vaccine, please select not applicable.Please select the type of High Risk Vaccine you need.Not ApplicableHaemophilus InfluenzaHepatitisHPVMeningtisPneumoniaHaemophilus Influenza Type B (Act-HIB/Hiberix)Please select your eligibility and if you do not need this vaccine please select Not Applicable. Eligibility- > 5 years with:Not ApplicableHematopoietic stem cell transplant (HSCT) recipient (3 doses)Functional or anatomic asplenia (1 dose)Immunocompromised related to disease or therapy (1 dose)Bone marrow or solid organ transplant recipient (1 dose)Lung transplant recipient (1 dose)Cochlear implant recipient (pre/pose implant) (1 dose)Primary antibody deficiency (1 dose)Hepatitis A Vaccine (Havrix/Avaxim/Vaqta)Please select your eligibility and if you do not need this vaccine please select Not Applicable. Eligibility (2 doses)- > 1 year with:Not ApplicableChronic liver disease (including Hepatitis B and C)Persons engaging with intravenous drug useMen who have sex with menHepatitis B Vaccine (Recombivax HB/Engerix-B)Please select your eligibility and if you do not need this vaccine please select Not Applicable. Eligibility- >= 0 years with:Not ApplicableInfant born to HBV-positive carrier mothers (premature infant weighing <2,000 grams at birth)Infant born to HBV-positive carrier mothers (premature infant weighing >=2,000 grams at birth and full/post term infants)Household or sexual contact of chronic carrier or acute caseIndividuals engaging in intravenous drug useMen who have sex with men, individual with multiple sex partners, or history of a sexually transmitted diseaseNeedle stick injury in a non-health care settingChild <7 years old whose family has immigrated from country of high prevalence for hepatitis B and who may be exposed to hepatitis B carriers through their extended familyChronic liver disease including hepatitis CRenal dialysis or disease requiring frequent receipt of blood productsAwaiting liver transplantHepatitis A & B Vaccine (Twinrix)The vaccine will not protect against infection caused by other agents such as hepatitis C, hepatitis E and other pathogens known to infect the liver. It can be expected that hepatitis D will also be prevented by immunization with TWINRIX as hepatitis D (caused by the delta agent) does not occur in the absence of hepatitis B infection. Please select your eligibility and if you do not need this vaccine please select Not Applicable. Eligibility:Not ApplicableActive immunization against hepatitis A and hepatitis B virus infection in adults, adolescents, children and infants.HPV (gardasil 9)Please select your eligibility and if you do not need this vaccine please select Not Applicable. Eligibility- Males between 9-26 years with:Not ApplicableMales 9 to 26 years of age who identify as MSM and have no received HPV vaccine previouslyMeningococcal B Vaccine (Bexsero)Please select your eligibility and if you do not need this vaccine please select Not Applicable. Eligibility- Age 2 months to 17 years with:Not ApplicableFunctional or anatomic aspleniaComplement, properdin, factor D, or primary antibody deficiencyCochlear implant recipient-pre/post implantAcquired complement deficiencyHIVMeningococcal Polysaccharide Vaccine (Menomune)Please select your eligibility and if you do not need this vaccine please select Not Applicable. Eligibility- >= 56 years with:Not ApplicableFunctional or anatomic aspleniaComplement, properdin, factor D, or primary antibody deficiencyCochlear implant recipient-pre/post implantAcquired complement deficiencyHIVMeningococcal Conjugate Vaccine (Menactra)Please select your eligibility and if you do not need this vaccine please select Not Applicable. Eligibility- Age 9 months to 55 years with:Not ApplicableFunctional or anatomic aspleniaComplement, properdin, factor D, or primary antibody deficiencyCochlear implant recipient-pre/post implantAcquired complement deficiencyHIVPneumococcal Conjugate Vaccine (Prevnar 13)Please select your eligibility and if you do not need this vaccine please select Not Applicable. Eligibility->= 50 years with:Not ApplicableHematopoietic stem cell transplant (HSCT)*HIVAsplenia (functional or anatomic)Sickle cell disease or other hemogloinopathiesCogenital immunodeficiencies involving any part of the immune system, including B-lymphocyte (humoral) immunity, T-lymphocyte (cell) mediated immunity, complement system (properdin or Factor D deficiencies), or phagocytic functionsImmunocompromising therapy including use of long-term corticosteroids, chemotherapy, radiation therapy, post-organ transplant therapy, biologic and certain anti-rheumatic drugsMalignant neoplasms including leukemia and lymphomaSolid organ or islet cell transplant (candidate or recipeient)Pneumococcal (Pneumovax 23)Please select your eligibility and if you do not need this vaccine please select Not Applicable. Eligibility- 2-64 years with:Not ApplicableAsplenia (functional or anatomic)Cardiac disease (chronic)Cerebral spinal fluid leak (chronic)Cochlear implant recipient (pre/post implant)Cogenital immunodeficiencies involiving any part of the immune system, including B-lymphocyte (humoral) immunity, T-lymphocyte (cell) mediated immunity, complement system (properdin or Factor D deficiencies), or phagocytic functionsDiabetes mellitusHIVImmunocompromising therapy including use of long-term corticosteroids, chemotherapy, radiation therapy, post-organ transplant therapy, biologic, certain anti-rheumatic drugs, and other immunosuppressive therapyLiver disease (chronic), including HBV/HCV and hepatic cirrhosisMalignant neoplasms, including leukemia and lymphomaRenal disease (chronic), including nephrotic syndromeRespiratory disease (chronic), excluding asthma, except those treated with high-dose corticosteriod therapySickle-cell disease and other sickle cell haemoglobinopathiesSolid organ or islet cell transplant (candidate or recipient)Neurologic conditions (chronic) that may impair clearance of oral secretionsHematopoietic stem cell transplant (HSCT) candidate or recipientResidents of nursing homes, homes for the aged and chronic car wounds Do you have any allergies?IE Latex, medications, vaccines, or components of vaccines, etc. Yes No Please identify your allergies below:Do you have any health conditions?IE bleeding disorders, chronic illnesses, neurological disorders, etc. Yes No Please identify your health conditions below:Do you have any conditions that can suppress your immune system?IE HIV infection, organ transplant, etc? Yes No Please identify your conditions that can suppress your immune system below:Have you experienced a reaction to a vaccine in the past?IE fainting, anaphylaxis, etc Yes No Please describe your experience to the vaccine below:Are you pregnant or considering becoming pregnant within the near future? Yes No Not Applicable Do you or your child require specific accommodations?IE reduction of sensory stimulus, fear of needles, etc. Yes No Please identify yours your your child's specific accommodation requirements below:Have you received a vaccine in the last 6 weeks? Yes No Please identify the vaccine you received below: NotesIf there is anything we should know before your appointment or about the vaccination please let us know below.Consent* I agree to give my consent to this document.By consenting to this document, I (as the patient) confirm that this information is accurate, to the best of my knowledge. CommentsThis field is for validation purposes and should be left unchanged.
