Downloadable Forms
Be Prepared For Your Visit
We highly recommend completing the forms corresponding to your appointment prior to your visit. This will reduce the amount of paperwork filled out in the office and help reduce wait time. Please remember to provide forms upon check-in to the front desk.
If these forms are not completed prior to the appointment, please arrive 15 minutes before the appointment time.
- Please bring your insurance card to every visit.
- Please call our office at (708)-923-6300 if you have any questions.
Chickenpox
| Vaccine | Varicella vaccine protects against chickenpox. |
| Spread By | Air, direct contact |
| Symptoms | Rash, tiredness, headache, fever |
| Complications | Infected blisters, bleeding disorders, encephalitis (brain swelling), pneumonia (infection in the lungs) |
Diphtheria
| Vaccine | DTaP* vaccine protects against diphtheria. |
| Spread By | Air, direct contact |
| Symptoms | Sore throat, mild fever, weakness, swollen glands in neck |
| Complications | Swelling of the heart muscle, heart failure, coma, paralysis, death |
Hib
| Vaccine | Hib vaccine protects against Haemophilus influenzae type b. |
| Spread By | Air, direct contact |
| Symptoms | May be no symptoms unless bacteria enter the blood |
| Complications | Meningitis (infection of the covering around the brain and spinal cord), intellectual disability, epiglottitis (life-threatening infection that can block the windpipe and lead to serious breathing problems), pneumonia (infection in the lungs), death |
Hepatitis A
| Vaccine | HepA vaccine protects against hepatitis A. |
| Spread By | Direct contact, contaminated food or water |
| Symptoms | May be no symptoms, fever, stomach pain, loss of appetite, fatigue, vomiting, jaundice (yellowing of skin and eyes), dark urine |
| Complications | Liver failure, arthralgia (joint pain), kidney, pancreatic, and blood disorders |
Hepatitis B
| Vaccine | HepB vaccine protects against hepatitis B. |
| Spread By | Contact with blood or body fluids |
| Symptoms | May be no symptoms, fever, headache, weakness, vomiting, jaundice (yellowing of skin and eyes), joint pain |
| Complications | Chronic liver infection, liver failure, liver cancer |
Influenza (Flu)
| Vaccine | Flu vaccine protects against influenza. |
| Spread By | Air, direct contact |
| Symptoms | Fever, muscle pain, sore throat, cough, extreme fatigue |
| Complications | Pneumonia (infection in the lungs) |
Measles
| Vaccine | MMR** vaccine protects against measles. |
| Spread By | Air, direct contact |
| Symptoms | Rash, fever, cough, runny nose, pinkeye |
| Complications | Encephalitis (brain swelling), pneumonia (infection in the lungs), death |
Mumps
| Vaccine | MMR** vaccine protects against mumps. |
| Spread By | Air, direct contact |
| Symptoms | Swollen salivary glands (under the jaw), fever, headache, tiredness, muscle pain |
| Complications | Meningitis (infection of the covering around the brain and spinal cord) , encephalitis (brain swelling), inflam mation of testicles or ovaries, deafness |
Pertussis
| Vaccine | DTaP* vaccine protects against pertussis (whooping cough). |
| Spread By | Air, direct contact |
| Symptoms | Severe cough, runny nose, apnea (a pause in breathing in infants) |
| Complications | Pneumonia (infection in the lungs), death |
Polio
| Vaccine | IPV vaccine protects against polio. |
| Spread By | Air, direct contact, through the mouth |
| Symptoms | May be no symptoms, sore throat, fever, nausea, headache |
| Complications | Paralysis, death |
Pneumococcal
| Vaccine | PCV vaccine protects against pneumococcus. |
| Spread By | Air, direct contact |
| Symptoms | May be no symptoms, pneumonia (infection in the lungs) |
| Complications | Bacteremia (blood infection), meningitis (infection of the covering around the brain and spinal cord), death |
Rotavirus
| Vaccine | RV vaccine protects against rotavirus. |
| Spread By | Through the mouth |
| Symptoms | Diarrhea, fever, vomiting |
| Complications | Severe diarrhea, dehydration |
Rubella
| Vaccine | MMR** vaccine protects against rubella. |
| Spread By | Air, direct contact |
| Symptoms | Children infected with rubella virus sometimes have a rash, fever, swollen lymph nodes |
| Complications | Very serious in pregnant women—can lead to miscarriage, stillbirth, premature delivery, birth defects |
Tetanus
| Vaccine | Adacel/DTaP* vaccine protects against tetanus. |
| Spread By | Exposure through cuts in skin |
| Symptoms | Stiffness in neck and abdominal muscles, difficulty swallowing, muscle spasms, fever |
| Complications | Broken bones, breathing difficulty, death |
Meningitis
| Vaccine | Menactra protects against meninigococcal meningitis |
| Spread By | exchange of respiratory secretions, such as coughing, sharing drinking glasses, and kissing |
| Symptoms | fever, headache, stiff neck, nausea, vomiting, photophobia, confusion |
| Complications | Brain damage, amputation, kidney damage, death |
HPV
| Vaccine | Gardasil 9 protects against HPV (Human papillomavirus) |
| Spread By | sexual contact |
| Symptoms | Often asymptomatic, symptoms may include warts on the genitals or surrounding skin |
| Complications | cancer in the cervix and genitals for both men and women. HPV infection can also cause cancer in the back of the throat. |