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Get Meningococcal Vaccine Consent Form

? yes no 2. Have you ever had a reaction to any immunization in the past? yes no yes no 3. Do you understand what the needle is for? 4. Are you allergic to the following: i/ Latex ii/ Diptheria Toxoid iii/ Other yes no yes no yes no 5. Have you ever been diagnosed with Guillain-Barre Syndrome (GBS) yes no yes no yes no Do you have any serious health problems, i.e. seizures, paralysis, history of fainting? yes no Are you taking any medication that may lower your im.

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