Step 1

Personal details

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Date *

Address Form

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Address 2

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Phone *

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Are you pregnant?

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Step 2

Medical Checklist

Past/Current Medical problems. (Please List) *

Are you taking any medication ? . (Please List) *

Please list allergies if any:

I have decided that I wish to take recommended vaccine for Influenza Vaccine

I understand that by accepting the vaccine I am aware of possible complications and/or side affects.

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Date: *

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