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Tdap (Tetanus, Diphtheria, Pertussis) Immunization - UMPA 2026

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The document is a Tdap (Tetanus, Diphtheria, Pertussis) Immunization Consent Form from University Medical Practice Associates. It includes a series of questions regarding the recipient's medical history and potential allergies to determine eligibility for vaccination. The form outlines individuals who should not receive the vaccine, possible side effects, and requires the recipient's consent after being informed about the risks and benefits of the vaccination.

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Click ‘Get Form’ to open the Tdap Immunization Consent Form in the editor.
Begin by entering the recipient's first and last name in the designated field. Ensure accuracy for proper identification.
Next, input the birth date in the format provided (MM/DD/YYYY). This is crucial for age verification.
Proceed to answer each question by circling YES or NO. If you have any uncertainties, feel free to ask for assistance.
Review the section regarding individuals who should not be vaccinated. Make sure to check if any of these apply to you.
In the consent section, initial where indicated after reading the Vaccine Information Statement (VIS) and understanding the risks and benefits.
Finally, sign and date the form at the bottom. Ensure that all information is complete before submission.

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Versions	Form popularity	Fillable & printable
2013	4.2 Satisfied (37 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Do I really need a Tdap shot?

One of the most common reasons pregnant patients decline the TDAP is because theyve already had the vaccine within the past 10 years, or during a previous pregnancy. This logic makes sense for general adult care, since the TDAP booster is usually given every 10 years.