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Get CA CDPH 8608P IMM-542P 2017

NUMBER KNOWN REACTIONS TO VACCINES/ALLERGIES PRACTICE NAME/ADDRESS Female VACCINES FOR CHILDREN (VFC) ELIGIBILITY (check one) No health insurance CHDP/Medi-Cal eligible Under-insured (insurance does not cover immunizations) may be vaccinated with VFC vaccines only at federally qualified and rural health centers American Indian/ Alaskan Native Not eligible If a combination vaccine (e.g., DTaP+IPV+HepB or DTaP+IPV+Hib) is used, record dose in each section. VACCINE DOSE HepB 1 HepB 2 .

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