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Vaccine Consent Form

Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Vaccine(s) Requested(Required)
Vaccine(s) Requested(Required)

Please Answer These Questions

Do you have any allergies to medications, substances or vaccines?(Required)
Do you have any food allergies to eggs?(Required)
Have you ever had Gullian Barre Syndrome?(Required)
Do you have any acute lung problems at this time? (Bronchitis, Pneumonia etc.)(Required)
Have you ever had a severe reaction to a vaccine?(Required)
Are you currently suffering from a fever?(Required)
MM slash DD slash YYYY
Consent(Required)