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Potomac Primary Care Patient Consent Form for Seasonal Influenza Vaccine Potomac Primary Care Patient Consent Form for Seasonal

Potomac Primary Care Patient Consent Form for Seasonal Influenza Vaccine Potomac Primary Care Patient Consent Form for Seasonal

Use a seasonal influenza vaccine consent form 0 template to make your document workflow more streamlined.

Children 3-8 years 0. Please print Name Date of Birth // FIRST MIDDLE LAST Parent or Guardian s Name if applicable Has the person receiving the vaccine ever had a severe allergic hypersensitivity reaction to eggs chickens or chicken feathers Yes No Does the person receiving the vaccine have a history of Guillain-Barr syndrome or a persistent neurological illness Yes No No If yes LAIV contraindicated TIV recommended vaccine ingredient or latex Yes No For child 6 mo-8 yrs have they received 2 or...
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