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Bend, Oregon 97701
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Forms
Vaccine Consent Form
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Today's Date
MM slash DD slash YYYY
Vaccine(s) Requested
(Required)
Influenza
COVID-19
Hepatitis A
Hepatits B
Thyphoid
Polio
Japanese Encephalitis
Rabies
Other
Select All
Vaccine(s) Requested
(Required)
MMR
T-dap
Zoster/Shingles
Yellow Fever
Varicella/Chicken-Pox
Tetanus
Meningococcal
Other
Select All
Please Answer These Questions
Do you have any allergies to medications, substances or vaccines?
(Required)
Yes
No
Do you have any food allergies to eggs?
(Required)
Yes
No
Have you ever had Gullian Barre Syndrome?
(Required)
Yes
No
Do you have any acute lung problems at this time? (Bronchitis, Pneumonia etc.)
(Required)
Yes
No
Have you ever had a severe reaction to a vaccine?
(Required)
Yes
No
Are you currently suffering from a fever?
(Required)
Yes
No
Date
(Required)
MM slash DD slash YYYY
Consent
(Required)
I agree.
I understand that all medications have risks associated with their use. I have answered all the above questions truthfully and to the best of my knowledge. I was offered or received a copy of the vaccine information sheet on this year's current influenza vaccine. This is put out by the CDC.
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