Family Healthcare of Fairfax, P.C. 
            
                
                
                    
                
            
                
                
                    
                
            
                
                
            
                
                
            
                Adverse reactions may occur if certain vaccines are given with the above conditions present.  <br/>A medical waiver may be used to complete immigration paperwork requirements if any of the above are present.
                
                
                
                    
                
            
                Please list type of surgery and year it was done
                
                
                
                    
                
            
                RX or over the counter, please list which medications you are taking
                
                
                
                    
                
            
                If yes, please list to what and reaction