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Rite Aid Screening Questionnaire and Consent Form

Rite Aid Screening Questionnaire and Consent Form

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Weight if less than 110 lbs.: ________ **FOR EMERGENCY USE ONLY** *Primary Care Physician (PCP): _________________________________ *Dr. Phone: ____________________ *PCP address- City ________________________ State______ Zip Code____________ Email Address _______________________________________________________ ________________________________________________________________________________________________________________________ The following questions will help us determine which vaccines may...
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