Consent for Influenza Immunization - Seattle
Consent for Influenza Immunization Group Health Members
First Name MI
| | | |
Last Name
| |
Address
| |
City State ZIP
| | | | | |
Age Date of Birth Male Female
| | |
|Signature |Date |
|FOR | | | | |
|NURsES | | | | |
|TO | | | | |
|CoMPLET| | | | |
|E | | | | |
| |Influenza Vaccine Card/Sticker | | | |
| |Date of Administration | | | |
| |Nurse Signature | |Date | |
| |Doctor Signature | |Date | |
-----------------------
146DS 09-09
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