CERTIFICATE OF IMMUNIZATION
FLU VACCINE 2004/2005
The 2004/2005 trivalent vaccine strains are A/Pabanab/2007/99(H3N2) (A/ Moscow/10/99(H3N2); A/New Caledonia/20/99(H1N1);B/Hong Kong/330/2001 hemagglutinin antigens.
The immunization given to me was:
Fluvirin (Chiron)
766055
Flu vaccine given by: (print) _________________________________
Signature: ___________________________
Date:__________________
You should receive your next flu shot in or after October, 2005
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I hereby agree that I will inform my physician, or other medical personnel who offer me the flu vaccine, that I have already received immunization this year. I take responsibility to include this certificate with my medical records.
_________________________________________ Signature
________________________ Date