Get University Of Tennessee Vaccine Administration Record (VAR) Informed Consent For Vaccination For 2019
MI Home Address Age Gender Male Female Last Name City State Primary Care Physician Name Zip Code Physician Phone SECTION B The following questions will help us determine your eligibility to be vaccinated today. For All Vaccines: Please answer questions 2-10. YES NO 1. Which vaccines are you requesting to have administered today? (PLEASE CIRCLE): 1) FLU 2) PNEUMONIA (13 -OR- 23) 3) GARDASIL (HPV) 4) Tdap 5) Td (TETANUS) 6) SHINGRIX (SHINGLES) 2. 3. 4. 5. 6. 7. 8. 9. 10. 7) VARICELL.
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