Author: Brenda Buck

Teen immunization / Immunization Consent and History	Livingston County Health Center / 800 Adam Drive Chillicothe, MO 64601

Last Name	First Name MI	Male/Female	Date of Birth

Street Address City State Zip Code		Phone	Age

Race	Ethnicity
□ White □ Black / □ Alaskan/Native American □ Asian / □ Hawaiian/Pacific Islander □ Hispanic/Latino / □ Bi Racial or Multi Racial	□ Non-Hispanic □ Cuban / □ Mexican □ Central/South American / □ Puerto Rican □ Other

Insurance Information
______ MoHealth/Medicaid ______ Private Insurance* ______ I Am Uninsured / Does your insurance pay for vaccinations? ____ No ____Yes / *Please Provide These Details About Private Insurance / Insurance Carrier: _______________________________________________ / Primary Insured____________________________________ Date of Birth ________________________ / Member ID _________________________________ Group ID ____________________________________

Vaccine Information Statements
□ Tdap 08-06-2021	□ MCV4/MPSV4 08-06-22

I have been given a copy of and have read, or had explained to me, the information in the “Vaccine Information Statements” for the vaccines indicated above. I understand the benefits and risks of the vaccines and ask that the vaccines be given to me or the person named above for whom I am the authorized to make this request pursuant to Section 431.058,RSMo. VIS Date 08/06/2021
X__________________________________________________________________________________________________
Authorized Signature Relationship Date

ALL SERVICES PROVIDED ON A NON DISCRIMINATORY BASIS

Modified 02/2022

Screening Checklist / for Contraindications to / HPV, MenACWY, MenB and Tdap Vaccines for Teens
For parents/guardians: The following questions will help us determine if human papillomavirus (HPV), meningococcal conjugae (MenACWY), meningococcal serogroup B (MenB), and tetanus, diphtheria, and acellular pertussis (Tdap) vaccines may be given to your teen today. If you answer “yes” to any question, it does not necessarily mean your child should not be vaccinated. It just means additional questions must be asked. If a question isn’t clear, please ask a nurse to explain it.
		yes	no	don’t know
1.	Is the child sick today?	¨	¨	¨
2.	Does your teen have allergies to a vaccine component, or to latex?	¨	¨	¨
3.	Has your teen ever had a serious reaction to a vaccine in the past?	¨	¨	¨
4.	Has your teen had brain or other nervous system problems?	¨	¨	¨
5.	For females: Is your teen pregnant?	¨	¨	¨
6.	Has your teen ever felt dizzy or faint before, during or after a shot?	¨	¨	¨
7.	Is your teen anxious about getting a shot?	¨	¨	¨

PATIENT NAME
DATE OF BIRTH _______ / _______ / _________
MONTH DAY YEAR

Form completed by: (PLEASE PRINT) DATE

VACCINE:	VACCINE:	VACCINE:
Mfr/Lot Exp Date	Mfr/Lot Exp Date	Mfr/Lot / Exp Date
Site Initials	Site Initials	Site / Initials

VACCINE:	VACCINE:	VACCINE:
Mfr/Lot Exp Date	Mfr/Lot Exp Date	Mfr/Lot / Exp Date
Site Initials	Site Initials	Site / Initials

Signature and Title of Vaccine Administrator Date Administered and VIS Given