Rabies Vaccine Consent From
What is Rabies?
Rabies is a virus which causes an acute infectious disease in mammals. It is often present in the saliva of
infected (rabid) animals. The disease is transmitted by a rabid animal biting another animal/human, or by
exposure to the infected animal’s saliva on an open wound or mucous membrane. The incubation period
is 10 days to one year. Usually, symptoms begin between 30 to 50 days following exposure. The virus
affects nervous tissue in humans. Common initial symptoms are restlessness, tiredness and fever. As the
disease progresses, symptoms of uncontrollable excitement with excessive salivation and painful
laryngeal/pharyngeal spasms can occur.
Indications
The vaccine is indicated for veterinarians, some laboratory workers and animal handlers.
Dosage
The Rabies vaccine is given in three doses at the following intervals:
 Initial dose
 Second dose given one week later
 Third dose given 21 to 28 days following the initial dose
The vaccine is proven effective for up to two years. It is recommended that immunity status be checked
every two years and booster doses be given if indicated.
Possible side effects of the vaccine
The most common side effects of the vaccine are soreness, swelling and pain at the site of injection. As
with any vaccine, there is a slight chance of allergic or more serious reactions.
Consent
I have read the above information and had it explained to me. I have had the opportunity to ask questions.
I believe I understand the benefits and risks of the rabies vaccine. I give consent that the rabies vaccine
be given to me as part of my treatment.
Patient Signature _____________________________________________ Date ____/____/____
Witness Signature ______________________________________________ Date ____/____/____
Declination
I have read the above consent and understand the risks and benefits of the vaccine and decline the vaccine
at this time.
Patient Signature _____________________________________________ Date ____/____/____
Witness Signature ______________________________________________ Date ____/____/____
If you decline the vaccine, please indicate your reason ______________________________________
__________________________________________________________________________________
Rabies Vaccine Consent Form
Patient Name ________________________________________________ Date _____/______/______
Vaccination status
□
Never vaccinated
□
Vaccinated no documentation
□
Vaccinated more than two years ago
Pre-testing blood work: (Rabies Endpoint Titer)
Date Drawn _____/_____/_____
Results:
□
Immune
□
Susceptible
Rabies vaccination series
1. 1 ml IM
□
Left Deltoid
□
Right Deltoid
Date ____/____/____ Lot # _________________
Nurses Signature ________________________________________
2. 1 ml IM
□
Left Deltoid
□
Right Deltoid
Date ____/____/____ Lot # _________________
Nurses Signature ________________________________________
3. 1 ml IM
□
Left Deltoid
□
Right Deltoid
Date ____/____/____ Lot # _________________
Nurses Signature _______________________________________
Post vaccination blood work
Date due: _____/_____/_____ Date done: _____/_____/_____ Results:
□
Immune
□
Susceptible
Rabies boosters
1. 1 ml IM
□
Left Deltoid
□
Right Deltoid
Date ____/____/____ Lot # _________________
Nurses Signature ________________________________________
2. 1 ml IM
□
Left Deltoid
□
Right Deltoid
Date ____/____/____ Lot # _________________
Nurses Signature ________________________________________
3. 1 ml IM
□
Left Deltoid
□
Right Deltoid
Date ____/____/____ Lot # _________________
Nurses Signature ________________________________________
Please mark your calendar as a reminder for vaccination and follow-up as scheduled. This form also
serves as a record of your vaccination.