Consent for Gardasil® Injection

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CONSENT FOR GARDASIL® INJECTION

Patient Name: MR#: D.O.B. Please Print

Please write your initials on the line after each statement as acknowledgement that you understand the statement(s), the explanation(s) given to you by your provider and that all your questions have been answered.

Gardasil® is a vaccine (injection/shot) that helps protect against female genital disease caused by Human Papillomavirus (HPV) Types 6, 11, 16, 18. These diseases include some forms of cervical cancer, abnormal precancerous lesions of the cervix, vagina, vulva and genital warts. Initials______

Human Papillomavirus (HPV) is a common virus. There are many types of HPV. Some cause no harm. Some cause diseases of the genital area. For most people, the virus goes away on its own. When the virus does not go away, it can develop into cervical cancer, precancerous lesions or genital warts depending on the HPV type. You may benefit from Gardasil® if you already have HPV. This is because most people are not infected with all four types of HPV. Initials______

Gardasil® helps prevent these diseases, it does not treat them. Gardasil® does not prevent any other sexually transmitted diseases like Chlamydia, gonorrhea, herpes, or HIV. It only protects against those diseases causes by the HPV types 6, 11, 16, 18. Initials______

Gardasil® is given as an injection in 3 doses. You will need to return in 2 months and in 6 months for your second and third doses. Initials______

Gardasil® should not be given if you are allergic to any of the following substances: Aluminum hydroxyl phosphate sulfate, Sodium Chloride (salt), L-Histidine, Polysorbate 80, Sodium Borate and Water. Gardasil® is not recommended for use in pregnant women. Initials______

The most common side effects of Gardasil® injection are fever, pain, swelling, itching and redness at the injection site. A rare side effect is difficulty breathing. Please alert your physician if you have any unusual or sever symptoms.Initials ______

Gardasil® does not eliminate the need for continued gynecological care, recommended Pap smears and screening for sexually transmitted diseases. Initials______

All my questions have been answered, and I did receive complete written patient information on Gardasil®. Initials______

I understand to schedule appointments for myself or for my minor child for the 2nd injection in 2 months and for the 3rd injection in 6 months from the date of the first injection dose.Initials ______

Although your medical provider and the US Center for Disease Control & Prevention (CDC) feel that Gardasil vaccination is medically necessary for females age 9 to 26, some insurance plans may not yet provide benefits for Gardasil injection. By signing on the line below, you are acknowledging that you have read this form, understand it and choose to have Gardasil injection for yourself or your minor child. Your signature also acknowledges that you are financially responsible for fees billed for these services.

INJECTION 1 Signature of Patient/Parent/Guardian/Agent Date

Witness Date INJECTION 2 Signature of Patient/Parent/Guardian/Agent Date

Witness Date INJECTION 3 Signature of Patient/Parent/Guardian/Agent Date

Witness Date