Immunization Consent Form

This is only an example of the types of questions asked on the U-M OHS immunization consent form. Please do not use this form to document vaccines that are administered. Please call U-M OHS 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?