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Rexall Consent Flu Form
Immunizations previously?
3.
Do you have allergies to medications, food (e.g. eggs), vaccine components, or latex?
Yes
No
Yes
No
4. Are you currently under a physician’s care for any medical condition (e.g. active neurological disorder)?
5.
Do you have any heart, lung, or diabetic condition?
6.
Have you had close contact with anyone with a severely weakened immune system?
7.
Do you have a history of Oculo-Respiratory Syndrome?
8. D
9.
Have you received your Shingles vaccines?
10....
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