1) Is your child 4 years or older?
2) Do any of the following apply to your child? (If you answer YES, your child cannot receive a Flu Vaccine at school - please contact your child's doctor)
• Allergy to chicken eggs or egg products
• Life threatening reaction(s) to flu vaccine in the past Allergy to Latex
• Has had Guillain-Barre syndrome (very rare)
3) Do any of the below apply to your child?
• Has long-term health problems with weakened immune system, heart disease, lung disease (e.g. cystic fibrosis), liver disease, kidney disease, or metabolic disorders (e.g. diabetes) or blood disorders (e.g. sickle disease or thalassemia)
I acknowledge that Aurora Concepts provided me and I have been afforded the opportunity to read the Notice of Privacy Practices and CDC Vaccine Information Statement for the vaccine(s) indicated on their website: www.auroraconcepts.net under the ‘Patient Resources’ tab.
I give permission to Aurora Concepts and their administrators to give my child the vaccine in my absence, to communicate with other healthcare providers, as needed, and for data entry, billing and storage according to Texas Department of Health policies, to assure optimal healthcare for my child. I hereby release Aurora Concepts, and my child’s school district from any and all liability associated with the administration and potential side effects of the vaccine.