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Clinic Card 1.
County Borough of West Ham.
Medical Officer of Health's Department.
PROTECTION ACAINST DIPHTHERIA.
I hereby consent to my child
born being innoculated against Diphtheria.
School attended (if any) Dept
Infant Welfare Centre attended (if any)
Signed
(Parent or Guardian)
Address
Date
Clinic Card 2. (Front).
County Borough of West Ham.
Medical Officer of Health's Department.
DIPHTHERIA IMMUNISATION at CLINIC
Name Date of Birth
(Surname first)
Address Date of Parents Consent
School (if any) Dept
Infant Welfare Centre (if any)
Previous illnesses
Immunisation Treatment.
Date Treatment and Remarks Signature of
Medical Officer
(Back) Shick Test after Treatment.
Date of Injection
Date of Examination after Injection
Result
Remarks
Signed
for F. GARLAND COLLINS,
Medical Officer of Health and School Medical Officer.
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