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Medicare Humana Gold Other Medicare Advantage Member Identification #: Patient s relationship to insured: Are you a Kaiser member? Self Spouse Child No Other Last Name: Birthdate: Yes First Name: Age: Sex: M MI: F Phone #: Street Address: City: State: Zip: PRECAUTIONS & CONTRAINDICATIONS Please Circle Have you ever had a flu shot before? Yes No Do you have a history of hypersensitivity to chicken eggs or egg protein? Yes No Do you have any hypersensitivit.

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