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Vaccine Documentation Form 252-9152 Vaccine Mfg. Lot No. Site Given Given by Hepatitis B DTaP/DT/DTP/Td/Tdap Hib PCV IPV/OPV RV MMR Measles Sarampi n Varicella Chickenpox Varicella History/Date of Varicella Disease MCV4 MPSV4 HPV PPSV VIS Date circle one Date Influenza TB Test Date Read Last/Apellido Birth date/Fecha de nacimiento mm First/Nombre Sex/Sexo Address/Direcci n Middle/Segundo nombre Race/Raza Telephone Number/N mero de tel fono City/Ciudad State/Estado Social Security Number/N mero de Seguro Social WIC Number/N mero de WIC Zip/C digo postal County/Condado Medicaid Number/N mero de Medicaid Parent s Name/Nombre del padre o de la madre Mother s Maiden Name/Apellido de soltera de la madre Department of State Health Services Immunization Branch Stock No. C-100 Revised 11/2010 Clinic Stamp I received or was offered a copy of the Vaccine Information Statement VIS for each vaccine. I know the risks of the disease each vaccine prevents. I know the benefits and risks of each vaccine. I have had a chance to ask questions about the disease the vaccines and how the vaccines are given* I know that the person receiving the vaccine will have the vaccine put into his/her body to prevent an infectious disease. I am an adult who can legally consent for the person named below to get the vaccine. I freely and voluntarily give my signed permission for the vaccines. Recib o se me ofreci una hoja con informaci n sobre cada vacuna VIS. Conozco los riesgos de las enfermedades que cada vacuna previene. Conozco los beneficios y riesgos que estas vacunas tienen* He tenido la oportunidad de hacer preguntas sobre las enfermedades las vacunas y c mo son administradas las vacunas. S que la persona recibiendo la vacuna la tendr en su cuerpo para prevenir una enfermedad contagiosa* Soy adulto y puedo dar permiso legalmente para que le den la vacuna a la persona nombrada abajo. Por mi propia voluntad firmo y doy permiso para que le den esta vacuna* Privacy Notification With few exceptions you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http //www. dshs. state. tx. us for more information on Section 552. 021 552. 023 559. 003 and 559. 004 Notificaci n Sobre Privacidad Tan solo por unas cuantas excepciones usted tiene el derecho de solicitar y de ser informado sobre la informaci n que el Estado de Texas re ne sobre usted* A usted se le debe conceder el derecho de recibir y revisar la informaci n al requerirla* Usted tambi n tiene el derecho de pedir que la agencia estatal corrija cualquier informaci n que se ha determinado sea incorrecta* Dir jase a http //www. dshs. state. tx. us para m s informaci n sobre la Notificaci n sobre privacidad* Referencia Government Code Secci n 552. 021 552. 023 559. 003 y 559. 004 copy of my immunization provider s HIPAA Privacy Notice. No HIPAA received Yes HIPAA received Witness Signature/Firma del Testigo Aviso sobre derechos de la vida privada Yo admito haber recibido una copia del aviso sobre derechos de la vida privada* Si Recib HIPAA Check vaccines to be given then enter date sign and complete the section below.

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