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