LEAGUE CITY FAMILY CLINIC
VACCINATION CONSENT FORM
Precautions and Contraindications (please
yes or no for each question
Are you allergic to medications or vaccines?
Have you had a serious reaction after receiving a vaccine?
For females: Are you pregnant now or could be in the next month?
Do you have a history of neurological problems, eg:Guillain- Barre
Have you received vaccination in the last 4 weeks?
Are you allergic to eggs, chickens or latex?
Should be Empty:
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