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FLU VACCINE FORM.pdf

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					                                  FLU VACCINE FORM
                    (Please fill out top of form and bring to your appointment.)

Date:_________
Patient name:________________________                         DOB:_____________

Egg allergy? Yes____ No____
Active Wheezing? Yes ____ No____

Prolonged Aspirin Therapy? Yes____ No ____
H/O Guillain-Barre syndrome?                   Yes____ No ____
(a severe paralytic illness also called GBS)

Signature of Parent/Guardian________________________

*************************************************************
FLU SHOT

6-35mo. ______ Lot#____________ Exp. Date_________ Site_____


3+years ______ Lot#____________ Exp. Date_________ Site_____



FLU MIST


2 years of age         Lot#_________ Exp. Date_________




Administrator initials:______________                 V.I.S. FORM GIVEN_______

				
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posted:7/16/2012
language:English
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