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