Consent for Influenza Immunization - Seattle



Consent for Influenza Immunization Group Health Members

First Name MI

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Last Name

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Address

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City State ZIP

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Age Date of Birth Male Female

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|Signature |Date |

|FOR | | | | |

|NURsES | | | | |

|TO | | | | |

|CoMPLET| | | | |

|E | | | | |

| |Influenza Vaccine Card/Sticker | | | |

| |Date of Administration | | | |

| |Nurse Signature | |Date | |

| |Doctor Signature | |Date | |

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146DS 09-09

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