Useful forms

The follow are forms that we use in our office.  In an effort to save waiting time these forms can be downloaded, printed and completed by the patient prior to their appointment.  Please let us know if you have a question about which form(s) you need to complete prior to your next visit.

2009 Patient Information Update Sheet
Patient Information Update Sheet for Minors
Lifetime Authorization
Menstrual History
Medical History Form
Consent to Use and Disclose Health Information
Notice of Privacy
Request for Confidential Communication of Protected Health Information
Authorization for Release of Medical Information

TDap facts

How effective is Tdap vaccine?
The vaccine protects:

  • more than 95 of 100 people against tetanus,
  • about 85 of 100 people against diphtheria and pertussis.

Immunizing teens against pertussis may reduce
community outbreaks and the spread of pertussis to
babies who are too young to be protected by

Are booster doses required?
It is not known how long the Tdap vaccine will provide protection against pertussis. A booster dose (of Td only) is recommended for adults every 10 years. The booster dose may be needed sooner if an adult gets a dirty wound or cut.
Who should receive the Tdap vaccine?
Immunization against tetanus, diphtheria and acellular pertussis is recommended for:

  • children over six years of age and adults whohave not completed their basic immunization series
  • children 14 to 16 years of age.

Who should not receive the Tdap Vaccine?
A doctor or public health nurse may decide not to give the vaccine to someone who:

  • has a high fever or infection worse than a cold (the vaccine can be given later)
  • has had a severe allergic reaction* to a previous dose of other vaccines
  • has a severe allergy to substances in the vaccine (e.g., aluminum phosphate,2-phenoxyethanol)
  • is in the first three months of pregnancy

* All severe allergies should be reported to the doctor or public health nurse before any shots are given.
How is the vaccine given?
The vaccine is given in a needle in the muscle of the upper arm.

Are there any side effects?
The Tdap vaccine is very safe. But as with any medicine, side effects sometimes occur. Minor side effects that usually disappear in two to
three days include:

  • soreness, redness and swelling where the injection is given
  • fever less than 39°C (102.5°F)
  • headache
  • not feeling well
  • feeling tired.

Acetaminophen (Tylenol® or Temprs®) can be given for fever. Never give acetylsalicylic acid (ASA or aspirin) to children. A cold damp cloth may help ease minor pain where the needle was given. Less common/rare side effects include:

  • severe swelling and pain where the needle is given. (This is unusual and happens whenvaccines containing tetanus and diphtheria are given too often.)
  • a small, painless lump where the needle was given. (This usually disappears within two months)
  • serum sickness (a rare illness that affects a number of organs in your body for a shorttime)
  • tingling, numbness or weakness in the arm and chest (less than one in 100,000immunizations)
  • severe allergic reactions such as:
    • hives
    • wheezing
    • shortness of breath
    • swelling of the face, mouth and throat (about one in 500,000 immunizations)
    • a temporary form of paralysis called Guillain Barre Syndrome. (about one in 2.5 million adult immunizations).

What are vaccines?
Vaccines are also called needles, baby shots, or immunizations. Vaccines help your immune system learn how to recognize the germs that cause diseases and fight them. Vaccines not only protect the people who are immunized but may also protect those who cannot be immunized for medical reasons. This is because someone who is immunized is less likely to spread infection. Before vaccines were available, little could be done to prevent serious diseases such as tetanus, diphtheria, pertussis (whooping cough), polio, measles and rubella. Now, very few Canadians get sick or die from these diseases because people are protected by immunization. However, in countries where these vaccines are not routinely used,  experience shows that these diseases could again become common in Canada if we do not continue to immunize against them.

What are these diseases?
The Tdap vaccine provides protection against:

  • diphtheria
  • tetanus (lockjaw)
  • pertussis (whooping cough).

Diphtheria was once a common disease Now there are no more than three or four cases a year, usually involving people who are not protected through immunization. Diphtheria bacteria (germs) infect the throat, nose or skin. The germs are passed on to others by:

  • coughing
  • sneezing
  • close face-to-face contact with an infected person

Diphtheria can cause:

  • breathing problems
  • weakness
  • loss of movement in muscles
  • heart failure
  • sometimes death

Diphtheria kills one of every 10 people who get the disease.
Tetanus bacteria (germs) cause the disease when they get into cuts, puncture wounds or burns. Tetanus germs are common, especially in dirt, dust and manure. The germs form a poison, or toxin, that causes muscles to tighten and go into spasms (painful, uncontrollable tightening of the muscles). Tetanus can be very serious if it affects the body’s breathing
muscles. About two of every 10 people who get tetanus will die.

Pertussis (whooping cough) Has recently increased again. These outbreaks have included a higher percentage of young teens (up to 30 per cent). This may be due to a slow drop in protection from the whole cell vaccine that these individuals received as children. Whole cell vaccine is no longer used. Pertussis germs, or bacteria, are easily spread through:

  • coughing
  • sneezing
  • close face-to-face contact with an infected person.

Older children, teens and adults can have a mild case of pertussis that goes undiagnosed and, as a result, may unknowingly infect babies and young children. Babies and young children, especially those who are too young to have been fully protected by immunization, can get very sick from pertussis germs. The disease causes long coughing spells that make it hard for a small child to eat, drink or even breathe. The disease may last up to three months and sometimes causes serious problems:

  • about one in five infants with pertussis hasto be hospitalized;
    • of these infants, one in 200 dies; and
    • about one in 400 suffers brain damage.

Gardasil the HPV vaccine

Primary Care Physician’s offers the Gardasil Vaccine.  Please contact the office today to inquire about this injection series.   The following facts are about HPV and the Gardasil Vaccine.

What is HPV? 

HPV (human papillomavirus) is a virus that is common in the United States and around the world and can cause cancer and genital warts. HPV is spread through sexual contact. There are about 40 types of genital HPV. HPV is the major cause cervical cancer in women and is also associated with several other types of cancer in both men and women.

How common is HPV?

HPV is the most common sexually transmitted infection in the United States. At least 50 percent of sexually active people will get HPV at some time in their lives. Every year in the U.S., about 6.2 million people get HPV. HPV is most common in young women and men who are in their late teens and early 20s.

Is HPV the same thing as HIV or herpes?

No, HPV is not the same as HIV or herpes virus (herpes simplex virus or HSV). While these are all viruses that can be sexually transmitted— HIV and HSV do not cause the same symptoms or health problems as HPV.

Can HPV be treated?

There is no cure for HPV. But there are treatments for the health problems that HPV can cause, such as genital warts, cervical cell changes, and cancers caused by HPV.

 What is the HPV vaccine?

The vaccine, Gardasil, is the first vaccine developed to prevent cervical cancer, precancerous genital lesions, and genital warts due to HPV.

Who should get the HPV vaccine?

CDC recommends the HPV vaccine for all 11 and 12 year old girls. The recommendation allows for vaccination to begin at age nine. Vaccination also is recommended for females aged 13 through 26 years who have not been previously vaccinated or who have not completed the full series of shots.

Are there other HPV vaccines in development?

Another HPV vaccine (being developed by GlaxoSmithKline) is in the final stages of clinical testing, but it is not yet licensed. This vaccine would protect against the two types of HPV that cause most cervical cancers.

How and when is the vaccine delivered?

The vaccine is given in a series of three injections over a six-month period. The second and third doses should be given at two and six months (respectively) after the first dose. HPV vaccine may be given at the same time as other vaccines.

Is the HPV vaccine effective?

This vaccine is highly effective in preventing four types of HPV in young women who have not been previously exposed to HPV. This vaccine targets HPV types that cause up to 70% of all cervical cancers and about 90% of genital warts. The vaccine will not treat existing HPV infections or their complications.

Is the HPV vaccine safe?

The FDA has licensed the vaccine as safe and effective. This vaccine has been tested in thousands of females (9 to 26 years of age) around the world. These studies have shown no serious side effects. The most common side effect is brief soreness at the injection site. CDC, working with the FDA, will continue to monitor the safety of the vaccine after it is in general use.

Does the vaccine contain thimerosal or mercury?

No, there is no thimerosal or mercury in the vaccine.

How long does vaccine protection last? Will a booster shot be needed?

The length of vaccine protection (immunity) is usually not known when a vaccine is first introduced. So far, studies have found that vaccinated persons are protected for five years. More research is being done to find out how long protection will last, and if a booster dose of vaccine will be needed .

Will girls/women be protected against HPV and related diseases, even if they don’t get all three doses?

It is not yet known how much protection girls/women would get from receiving only one or two doses of the vaccine. For this reason, it is very important that girls/women get all three doses of the vaccine.

Does the vaccine protect against cervical cancer?

Yes, HPV vaccine is the first vaccine developed to prevent cervical cancer. This new vaccine is highly effective in preventing HPV infection, the major cause of cervical cancer in women. The vaccine protects against four types of HPV, including two that cause about 70% of cervical cancer.

How common is cervical cancer?

The American Cancer Society estimates that in 2007, over 11,000 women will be diagnosed with cervical cancer and approximately 3,600 women will die from this disease.

Will the girls/women who have been vaccinated still need cervical cancer screening?

Yes, they will still need to see their healthcare provider for cervical cancer screening. There are three reasons why women will still need regular cervical cancer screening. First, the vaccine will NOT provide protection against all types of HPV that cause cervical cancer, so women will still be at risk for some cancers. Second, some women may not get all required doses of the vaccine (or they may not get them at the right times), so they may not get the vaccine’s full benefits. Third, women may also not get the vaccine’s full benefits if they have already acquired a vaccine HPV type.

Why is the vaccine only recommended for girls/women ages 9 through 26?

The vaccine has been extensively tested in 9 through 26 year-old females so information is only available about vaccine safety and protection for girls/women of this age group. However, studies on the vaccine are now being done in boys/men, as well as in women older than 26 years of age. The FDA will consider licensing the vaccine for these other groups when there is research to show that it is safe and effective in these groups.

Why is HPV vaccine recommended for girls 11 to 12 years of age?

It is important for girls to get HPV vaccine before they become sexually active. The vaccine is most effective for girls/women who get vaccinated before their first sexual contact. It does not work as well for those who were exposed to the virus before getting the vaccine. However, most women will still benefit from getting the vaccine because they will be protected against other virus types contained in the vaccine.

Should pregnant women be vaccinated?

The vaccine is not recommended for pregnant women. There has only been limited information about vaccine safety among pregnant women and their unborn babies. So far, studies suggest that the vaccine has not caused health problems during pregnancy, nor has it caused health problems for the child. But more research is still needed. For now, pregnant women should wait to complete their pregnancy before getting the vaccine. If a women finds out she is pregnant after she has started getting the vaccine series, she should wait until after her pregnancy is completed to finish the three-dose series.

What about vaccinating males?

We do not yet know if the vaccine is effective in boys or men. Studies are now being done to find out if the vaccine works to prevent HPV infection and disease in males. When more information is available, this vaccine may be licensed and recommended for boys/men as well.

Will my child be required to get the vaccine before she enters school?

There are no federal laws requiring the immunization of children. All school and daycare entry laws are state laws and vary from state to state. Therefore, you should check with your state health department of Board of Education to find out what vaccines your child will need to enter school or daycare.

Each year the CDC publishes childhood and adolescent immunization schedules that provide recommended timelines for immunization of children and adolescents. The annual childhood and adolescent immunization schedules are a joint effort of the CDC, the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). While these organizations have no regulatory authority over the immunization of children, the recommendations of the CDC, AAP, and AAFP are considered standards of medical practice and most physicians follow the recommendations.

How much will the HPV vaccine cost?

The retail price of the vaccine is $120 per dose ($360 for full series).

Will the vaccine be covered by insurance plans?

Most insurance plans and managed care plans cover recommended vaccines. However, there may be a lag-time after a vaccine is recommended, before it is available and covered by health plans. While some insurance companies may cover the vaccine, others may not.

How can I get the vaccine if I don’t have insurance?

The Vaccines for Children (VFC) program helps families of children who may not otherwise have access to vaccines by providing free vaccines to doctors who serve them. The VFC program provides free vaccines to children and adolescents younger than 19 years of age, who are either Medicaid-eligible, American Indian, or Alaska Native or uninsured. There are over 45,000 sites that provide VFC vaccines, including hospital, private, and public clinics. The VFC Program also allows children and adolescents to get VFC vaccines through Federally Qualified Health Centers or Rural Health Centers, if their private health insurance does not cover vaccinations. For more information about the VFC, visit