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Influenza Vaccination Consent Form 2015/16 Patient ID no. (you will find this no. on your repeat medication slip). Patient Details Please complete and Sign.
Flu Vaccine Form. Patient Name: Date: F: M: DOB: Age: Phone: Address: City: State: Zip: I, the undersigned, have read or had explained to me the vaccine
20 Sep 2011 Keeping providers informed about planned SLV clinics also will help them how much influenza vaccine they will need to order for their own patients. Student information contained in the vaccine consent form may be
Flu Vaccine Questionnaire/ Consent Form. Date: _____/______/______. Patient Name: DOB: 1.) Have you had a flu shot before? Yes No. 2.) Are you sick today
2015/16 INFLUENZA VACCINE CONSENT FORM. As of today: Have you received any vaccinations in the last 6 weeks? Do you have PATIENT CONSENT.
PATIENT CONSENT FORM FOR SEASONAL INFLUENZA VACCINE. Please Print: Name of Individual to be Immunized:
VACCINE. CONSENT FORM. I HAVE READ AND UNDERSTOOD FOR INFLUENZA VACCINE. I CONSENT. TO RECEIVING A FLU VACCINE. You must be assessed individually and provide informed consent by signing this form before.
This form confirms that you have given your consent to have an influenza vaccination. I have had a previous severe response to an influenza vaccination.
PATIENT CONSENT FORM. FOR SEASONAL INFLUENZA VACCINE. I have read, or have had explained to me, the CDC Vaccine Information Statement about
The national Flu Vaccination Record and Consent Form should be used to maintain a clinical record for the Flu Vaccination Service and to record patient
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