Vaccine Consent

Please read carefully: King’s Daughters Medical Center (“KDMC,” “we” or “us”) will offer a series of vaccinations during the course of the 2023-2024 school year. The vaccinations to be offered protect against the following conditions:

1. Tetanus-Diphtheria-Pertussis (“TDAP”) – Tetanus, diphtheria and pertussis are bacterial diseases that cause muscle pain, difficulty breathing, vomiting and a host of other symptoms, and can lead to serious health problems including but not limited to lockjaw, paralysis, heart failure and death. The TDAP vaccine is typically given in 1 dose (by shot). Potential side effects include but are not limited to soreness at the injection site, fever, headache, rash, body-aches or nausea.

2. Genital human papillomavirus (“HPV”) is the most common sexually transmitted virus in the United States. Most HPV infections don’t cause any symptoms, and go away on their own; however, HPV can cause cervical cancer in women. HPV is also associated with several less common cancers, such as vaginal and vulvar cancers in women, and anal and oropharyngeal (back of the throat, including base of tongue and tonsils) cancers in both men and women. HPV can also cause genital warts and warts in the throat. The HPV vaccine can prevent most cases of cervical cancer in females, if it is given before exposure to the virus. In addition, it can prevent vaginal and vulvar cancer in females, and genital warts and anal cancer in both males and females.

3. Meningococcal (“Meningitis”) – Meningitis is a serious bacterial illness, which can lead to infection of the lining of the brain and spinal cord and infections of the blood. The Meningitis vaccine is typically administered in 2 doses (each a shot). Potential side effects include but are not limited to redness or soreness at the injection site or mild fever.

4. Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus. The virus is one of several types of hepatitis viruses that cause inflammation and affect your liver’s ability to function. The hepatitis A vaccine is given as two shots, six months apart. The most common side effects are usually mild and last 1 or 2 days. They include the following: sore arm from the shot, headache, tiredness, fever, loss of appetite.

In order to receive a vaccination for any of the above conditions, student’s parent/legal guardian must complete this Vaccination Consent Form in addition to a separate Consent for Services form on file at school, both completed and signed by student’s parent or legal guardian.

Please complete this form and indicate which vaccinations you wish for student to receive. Please sign below as Parent/Guardian if you give permission to King’s Daughtetrs to administer the selected vaccinations to student.