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BCG vaccination consent form
"
*
" indicates required fields
1
Patient Details
2
Questions
3
Clinician to complete
4
Consent information
BCG vaccination consent form
Name
*
Date of Birth
*
MM slash DD slash YYYY
MANTOUX reading
Reading in mm
*
Time of Reading
*
Date of Reading
*
MM slash DD slash YYYY
Name of clinician
*
Signature
*
Action required:
0 - 4.99mm – is classed as a negative result and the BCG vaccine should be administered.
5mm and above – refer to GP for further investigation; vaccine should not be administered until further investigation.
Administering clinician to complete
Site of injection
*
Left deltoid
Right deltiod
Dose of vaccination 0.1ml intradermal
Batch Number
*
Expiry Date
*
MM slash DD slash YYYY
Comments
Name
*
Date
*
MM slash DD slash YYYY
Signature
*
BCG Patient information sheet
Image instead of text provided
Consent
*
I have been provided with and have read the information leaflet regarding the BCG Vaccine including any expected reaction and after care following the administration of the vaccine.
Consent
*
I understand the benefits and risks of having the vaccination including any potential side effects.
Name
*
Date
*
MM slash DD slash YYYY
Signature
*
Δ