Consent for Human Papillomavirus (HPV) Vaccination

Procedure Name

Form Sections

Section 1info grid

Clinical Practice Name

Attending Clinician

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Parent / Guardian Name (If Minor)

Planned Vaccine Dose

Section 2text block

Section 3list block

Section 4text block

Section 5list block

Section 6text block

Section 7text block

Section 8text block

Section 9signature block

Patient / Guardian Signature

Witness Signature (If Required)

Administering Clinician Signature

Consent for Human Papillomavirus (HPV) Vaccination

Patient and Guardian Information

Clinical Practice Name

Attending Clinician

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Parent / Guardian Name (If Minor)

Planned Vaccine Dose

Nature and Purpose of the Procedure

This document records authorization for the administration of the Human Papillomavirus (HPV) vaccine. The HPV vaccine is an immunization that protects against certain strains of HPV that cause cancer and other health complications. The vaccine series is recommended for adolescents and young adults. The clinician will administer the vaccine via an intramuscular injection in the upper arm or thigh. The vaccine series consists of two or three doses depending on the patient's age.

Material Risks and Potential Complications

Common mild side effects: pain, redness, or swelling at the injection site, low-grade fever, headache, or feeling tired.

Fainting (syncope): can occur after vaccination, particularly in adolescents. Patients are advised to sit or lie down for 15 minutes post-injection.

Severe allergic reactions (anaphylaxis): extremely rare but potentially life-threatening, requiring immediate medical care.

[Insert additional vaccine manufacturer clinical risks here]

Expected Benefits

Expected benefits include the development of active immunity against cancer-causing strains of HPV, reducing the risk of cervical, vaginal, vulvar, penile, anal, and oropharyngeal cancers.

Reasonable Alternatives

Choosing to delay the vaccination series until a later date.

Declining the HPV vaccination entirely and using non-vaccine preventive measures.

Vaccine Information Statement (VIS)

I acknowledge that I have been provided with and have read the Centers for Disease Control and Prevention (CDC) Vaccine Information Statement (VIS) for the HPV vaccine prior to administration.

Financial Responsibility

I understand that I am financially responsible for any non-covered vaccine administration fees or costs not paid by my insurance provider.

Patient Acknowledgment

I certify that I have read and understand this authorization form. I have been given the opportunity to ask questions, and all my questions have been answered satisfactorily. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request.

Signatures and Verification

Patient / Guardian Signature

Witness Signature (If Required)

Administering Clinician Signature

Document ID: CC-PENDING

CONSENTCOLLECT