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Back to School 2022 - TDAP & Meningococcal Vaccine Scheduling and Consent
Thursday August 11th - 11:00am to 3:00pm - Branson Jr High School - 263 Buccaneer Blvd, Branson MO 65616
For the person receiving the vaccines:
First Name
*
Middle Initial
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Sex
*
Male
Female
Do you have insurance?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State (Abbreviation i.e. MO)
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Taney County Resident?
*
Yes
No
Today
-
Month
-
Day
Year
Date
Health History
Health History
*
Yes
No
1. Do you have allergies to medications, food, vaccine component, or latex?
2. Have you had a serious reaction to a vaccine in the past?
3. Have you had a seizure; or had a brain or other nervous system problem?
4. Do you have a weak immune system (for example, from HIV, cancer, or medications such as steroids or those used to treat cancer)?
5. Are you pregnant or is there a chance you could become pregnant during the next month?
6. Have you received any vaccinations in the past 4 weeks?
For the parent or legal guardian:
First Name
Middle Initial
Last Name
Click submit below, then be sure to click the link on the next page to schedule your appointment.
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