School Consent Form - First District Health Unit

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Test School Vaccine Consent

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

Please select the school you are registering for*

Grade*

Provide information of person receiving vaccine. Use full legal name.

First Name*

First

Middle Initial

Middle

Last Name*

Last

Age*

Date of Birth*

Gender*

Male

Female

Address*

Street Address

City

ZIP Code

Preferred language*

English

Other

Race*

White

American Indian

African American

Alaska Native

Asian

Hispanic/Latino

Pacific Islander

Other

Unknown

Prefer not to answer

Please provide your contact information below.

Parent or Guardian's Full name*

Email*

Parent's Phone Number*

If we have questions regarding your child's immunization, may we contact you?*

Yes

No

How would you prefer we contact you?

Call

Text

Both

Please mark if you have the following health insurance and enter the insurance number.

Medicaid:*

Yes

No

Medicaid Number*

Primary Health Insurance*

Yes

No

Health Insurance Company – Primary*

Primary Insurance Number*

Secondary Health Insurance*

Yes

No

Health Insurance Company – Secondary*

Secondary Insurance number*

No Insurance*

No Insurance – Under 19 years will be billed $20.90 per vaccine. Financial assistance is available.

Health questions for the person who is receiving vaccines:

Ever felt dizzy or faint before, during or after a shot or blood draw?*

Yes

No

Any allergies to medications, food, or latex?*

Yes

No

Briefly list allergies*

Have a long-term health problem with lung, heart, kidney, liver, brain/nervous system, metabolic disease (e.g., diabetes), asthma, blood disorder, no spleen, a cochlear implant, or spinal fluid leak?*

Yes

No

Ever had a life threatening reaction to a vaccine in the past?*

Yes

No

On long-term aspirin therapy?*

Yes

No

Had a seizure or had a parent, brother, or sister who has had a seizure? Any brain or other nervous system problems?*

Yes

No

Have cancer, leukemia, HIV/AIDS, or any other immune system problems? Have a parent, brother, or sister with an immune system problem?*

Yes

No

In the past 6 months, taken medications affecting the immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Chron's disease, or psoriasis; or had radiation treatments?*

Yes

No

In the past year, received a transfusion of blood or blood products, or immune (gamma) globulin or an antiviral drug?*

Yes

No

Been diagnosed with a heart condition (myocarditis/pericarditis), or had a history of Multisystem Inflammatory Syndrome (MIS-C) after an infection with COVID virus?*

Yes

No

Had vaccinations in the past 4 weeks?*

Yes

No

Uses Tobacco or e-cigarettes?*

Yes

No

Pregnant or could become pregnant during the next month?*

Yes

No

Please check which vaccinations you authorize your child to receive:*

Vaccine:	Age:	Requirement:
Meningococcal ACWY	1st dose after age 11 2nd dose after age 16	1st dose required for entry into 7th grade. 2nd dose required for entry into 11th grade.

Vaccine:	Age:	Requirement:
Tdap (Tetanus, Diphtheria, Pertussis)	1 dose after age 11	Required for entry into 7th grade.

Vaccine:	Age:	Requirement:
HPV (Human Papillomavirus)	Age 9 and up	Recommended. 1st dose is typically given with other vaccines that are required for 7th grade. 2nd dose is given 6 months after 1st dose. 3rd dose may be recommended if the child’s first dose was received after age 15

Vaccine:	Age:	Requirement:
Meningococcal B	Age 16 and up	Recommended. 1st dose is typically given with other required vaccines at age 16. 2nd dose is given 6 months after 1st dose.

Vaccine:	Age:	Requirement:
Hepatitis A	Age 6 months and up	Recommended. Most children in the US have been fully vaccinated.

(Your student’s vaccination record will be checked before the clinic to ensure the selected vaccines are due.)

FDHU Vaccine information statement*

I have viewed the Vaccine information statement. I have read the information about the vaccine(s). I consent for immunizations to be given to the person named above AND am authorized to give consent. First District Health Unit (FDHU) Notice of Privacy Practices is available online. I agree to pay, and I am financially responsible for the charges not covered by a third-party payer. I assign and authorize any third-party payer/insurer to make direct payment to FDHU. I authorize the release of information necessary to process this claim. Information will be shared with the ND Immunization Information System. I AGREE THAT MY TYPED SIGNATURE ON THIS FORM BELOW IS THE LEGAL EQUIVALENT OF MY HAND WRITTEN SIGNATURE.

I have read and agree to the statement above.

Typed Signature*

First District Health Unit

801 11th Ave. SW
Minot, ND 58701
Phone: 701-852-1376

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