Consent for Tuberculin Skin Test

Step 1 of 2

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Name

Address

Date of Birth

City

State

Zip Code

Phone

1. Have you ever had TB skin test?

Yes

2. Have you ever had a positive reaction to a TB Skin Test?

Yes

3. Have you had any immunization within the past six weeks?

Yes

4. (Women only) If pregnant - have you discussed this with your Doctor

Yes

Reason test is needed

I have been informed that I am to return to Greater Home Health Services within 48-72 hours to read my skin test Monday - Friday only from 9.00am - 3.00pm

By signing this form, I acknowledge that I give permission to Greater Home Health Services and the staff to administer a Mantoux test on me.

Signature

Date

Record of Mantoux Test

Step 1

Date given

Date Read

Result

Time

Time Read

Manufacturer's Name

Lot Number

Site

Given by

Read by

Step 2