Milford Health Department Immunization Clinic- Tuberculin Test Consent Form

Please complete all required fields below. The Tuberculin Test information sheet is available after you select "Yes" to indicate your plan to have it administered to you. Please read and print these documents as they provide you details on the disease and the vaccine along with its benefits and risks.

Last Name *

First Name *

Address *

City *

State *

Zip code

Birthdate *

Phone number *

Family Physician *

Occupation *

Reason for testing (ie., Milford Public School employment, Daycare, School, etc) *

Vaccine to be given:

Tuberculin Test

Please read and print the Tuberculin Testing Information Document listed below for the test you plan to have administered to you. This information provides you details on the disease and the test along with its benefits and risks.

TB Testing information document

Please indicate if you would like to consult with a nurse before test administration to have an opportunity to discuss the concerning test. *

Yes

Please provide the best number to contact you

I have been given a copy and have read or had explained to me the tuberculin test information sheet about the indicated disease and the test. I have had a chance to ask questions of the Milford Health Department as well as the nurse and / or medical professional administering the test, which were answered to my satisfaction. I understand the benefits and risks of the test and ask that the test be given to me or the person named below for whom I am authorized to make this request. I am informed that i may refuse the test and that this refusal will not in anyway negatively affect my employment. *

Yes

Please type your name in the box as signature to receive the tuberculin test or person authorized to make the request *

Today's date *

Month

Day

Year

Leave this field blank

About Milford

Services

Government

City Departments

Boards & Commissions

Residents

Businesses

How Do I?

How Do I Find?

Milford Health Department Immunization Clinic- Tuberculin Test Consent Form