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Get OR MSSP Influenza Immunization Consent And Claim Form 2013

PacificSource Providence Patient Information (Please Print) Last Name: First Name: Date of Birth: / / Phone #: ( ) - MI: Sex: F M Street Address: City: Member Identification #: State: Have you ever had a severe reaction to a flu shot? Zip: Group #: YES NO Do you have a history of Guillain-Barre Syndrome? YES NO Are you allergic to eggs? YES NO Are are you pregnant? YES NO I have read/had explained to me the information.

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