Immunization Consent Form
This is only an example of the types of questions asked on the EHS immunization consent form. Please do not use this form to document vaccines that are administered. Please call EHS at 764-8020 to obtain actual consent forms which can be mailed or faxed to your site.
Potential contraindications:
- Do you currently have a fever?
- Do you have any chronic diseases affecting your immunity?
- Are you taking any medications which affect your immunity?
- Are you severely allergic to eggs?
- Are you allergic to the antibiotic neomycin?
- Are you allergic to gelatin?
- Are you allergic to latex?
- Are you allergic to the preservative thimerosal?
- Are you allergic to baker's yeast
- Have you had any immunizations, gamma globulin, or blood transfusions in the past three months?
- Women
Only: MMR and Varicella vaccines should not be given
during pregnancy or for 3 months prior to conception.
Caution should be exercised when giving Varicella vaccine to breastfeeding
women.
- Are you pregnant/planning to become pregnant in the next 3 months?
