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Get University Of Tennessee Vaccine Administration Record (VAR) Informed Consent For Vaccination For 2019-2024

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) (HPV) 4) Tdap 5) Td (TETANUS) 6) SHINGRIX (SHINGLES) 2. 3. 4. 5. 6. 7. 8. 9. 10. 7) VARICELL.

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