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Get Influenza (flu) Vaccine Consent Form

Ne Physician Name/Location 1. Do you have or have you ever had an allergy to eggs or egg products? Yes No 2. Have you ever been diagnosed with Guillain Barre syndrome (a progressive paralysis that goes away after a period of time)? Yes No 3. Are you pregnant? Yes No 4. Do you have any allergies to medication or food? What? Yes No I have read the information about the influenza (flu) vaccine and I feel that I should receive this immunization. I.

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