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Get and Sign Publix Vaccine Consent Form
Have a cold, fever, or acute illness? Do you have any allergies to medications, food, or any vaccine? List:________________________ Are you allergic to chicken eggs or egg product? Are you allergic to Thimerosal (cleaning products or contact lens solution)? Have you ever had a serious reaction after receiving a vaccination? Have you ever been diagnosed with Guillain-Barre’ syndrome? (for meningococcal) Do you have a seizure, brain, or nerve problem? (for pertussis) Do you have a weakened immune...Show details
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