Consent for Tuberculin Skin Test

Step 1 of 2

Facebook

This field is for validation purposes and should be left unchanged.

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