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Get Canada Seasonal Influenza And Pneumococcal Immunization Consent Form - Manitoba 2016-2024

Ient Information - please print Surname Given Names Address City/Town Home Phone Date of Birth (yyyy/mm/dd) Manitoba Health Number (6 digits) / Postal Code Gender Male / / Female Personal Health Information Number (9 digits) B. Health History of Client 1. Are you well today? If no, describe 2. Do you have any allergies? If yes, describe 3. Have you ever had a serious reaction or condition following any vaccine? If yes, describe 4. Do you have any conditions that require regular visit.

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