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HPV Immunisation Consent Form

YES, I consent for my child to receive the HPV immunisation

Please contact the immunisation team on 0333 358 3397

Please do not take your child to your Doctor to have this vaccine if you are giving consent for them to have it in school.

Childs Details

Child's Surname:

First Name:

Gender

Male
Female

Ethnicity:

Address:

Town/City:

Postcode:

Date of Birth

NHS Number (if known):

School:

Coal Clough High School

Year Group:

GP Name:

GP Address:

Town:

Postcode:

Parent/guardian Details

Surname:

First Name:

Telephone Number (preferably mobile):

E-mail Address:

I am happy for someone to contact me to find out what I thought of the service

Please contact me via the following methods:

Phone
Email

Please select how you would prefer to be contacted

Important information about this immunisation

Does your child have any long standing medical conditions or taking any regular medication?

Yes*
No

Does your child have any known allergies?

Yes*
No

Has your child ever had a serious allergic reaction to vaccinations that has required hospital treatment?

Yes*
No

*If you answered YES to any of the questions above, please give details below:

Informed Consent

*Please tick to confirm you have read and understand the information about the HPV vaccination, including the requirement for 2 doses. If you are unsure, please read the information again here

Your Acceptance

*YES, I consent for my child to receive the required 2 doses of HPV vaccine

Signature of parent / guardian (with parental responsibility):

Relationship to child:

It appears consent has already been recorded for this child, please contact the Immunisation Team on local rate 0333 358 3397. Our Nurse, Healthcare Assistants and Administrators are available Monday to Friday during working hours.

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Tel: 0333 3583 397
Fax: 0191 518 1656

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HPV Immunisation Consent Form

YES, I consent for my child to receive the HPV immunisation

It appears that you have cookies blocked or disabled.
Our site may not function correctly until you allow cookies on this site.