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Informed Consent Form for Bivalent Human Papillomavirus (HPV) Absorption Vaccine in Lishui City
Edit: Department of Education Source: Lishui Maternal and Child Health Hospital Release time: 2019-10-08 09:09 Read: 0 Times

Informed Consent Form for Bivalent Human Papillomavirus (HPV) Absorption Vaccine in Lishui City

 

Human papillomavirus (HPV) infection can cause a variety of diseases, of which cervical cancer is a serious disease caused by the persistent infection of carcinogenic HPV in the female reproductive tract. One person. Cervical cancer is a preventable disease. The World Health Organization (WHO) combines vaccination and cervical screening as a strategy for cervical cancer prevention and control. The bivalent human papillomavirus vaccine has a certain cross-protective effect against specific non-vaccine HPV types.In addition to HPV16 and 18, it can also provide protection against oncogenic HPVs such as HPV31, 33, and 45. CIN3 + (grade 3 of cervical intraepithelial neoplasia and adenocarcinoma in situ) has a protective effect of 93.2%. Vaccination can prevent viral infection and prevent cervical cancer, and the vaccine does not contain viral DNA, which will not cause infection and disease. 元/针 。 This vaccine belongs to the second type of vaccine, and the price is 608 yuan / needle . Seeds are voluntarily planted at their own expense .

接种本疫苗后,可刺激机体产生抗多型HPV病毒的免疫力,用于预防宫颈癌。 [Use] After inoculating this vaccine, it can stimulate the body to produce immunity against polytype HPV virus, and it is used to prevent cervical cancer.

9~45岁的女性。 [Recommended recipients] Females 9 to 45 years old.

[Immunization program and dosage]

(1) Intramuscular injection of this product, the preferred inoculation site is the deltoid muscle of the upper arm.

(2) This product is recommended to be inoculated one time each in 0, January and June, a total of 3 doses, each 0.5ml. According to foreign research data, the second dose can be inoculated between 1 and 2.5 months after the first dose, and the third dose can be inoculated between 5 and 12 months after the first dose.

十分常见:疲乏、肌痛、头痛、发热(≥37 °C)。 [Adverse reactions] Very common: fatigue, myalgia, headache, fever (≥37 ° C). The injection site responded to pain, redness, and swelling. Common: joint pain, gastrointestinal symptoms (including nausea, vomiting, diarrhea and abdominal pain), urticaria and rash. Most of the above adverse reactions are mild to moderate, and they can resolve on their own in a short time.

对疫苗中任一活性成分或辅料严重过敏反应者。 [Vaccination contraindication] Those who have severe allergic reaction to any active ingredient or excipient in vaccine. See the manual for details.

①接种后留观 30 分钟。 [Precautions] Watch for 30 minutes after vaccination . ② Provide relevant medical conditions to medical staff truthfully before vaccination. ③ Cervical cancer vaccine cannot prevent 100% of cervical cancer. The prevention of cervical cancer also needs regular cervical screening.

□ fever

□ Whether you have serious acute or chronic diseases

□ Is there a history of allergies?

□ Have you experienced allergic symptoms in previous vaccination?

□ Are you in the acute phase of the disease?

□ Are you pregnant or nursing?

○ Yes ○ No

○ Yes ○ No

○ Yes ○ No

○ Yes ○ No

○ Yes ○ No

○ Yes ○ No

To ensure that you can get your vaccination safely and effectively, please provide the following information to the medical staff (filled in by your doctor):

---------------- The following is filled in by the recipient or guardian --------------------

I have understood the above information, and the information provided is true, and I agree to vaccination.

Recipient name:                date of birth:          year       month       day

Signature of the recipient (or guardian): __________________ (under 18 years of age requires a guardian's signature)

Relationship between the guardian and the recipient: ○ Mother ○ Father ○ Other (please specify) _______________

Date: ________ year _______ month _______ day  

---------------- The following is filled in by the vaccination doctor --------------------

  接种医生签名: Vaccination site (marked √): upper left, upper right, lower left, lower right Signature of vaccination doctor:               


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