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IAN/PROVIDER NAME Section B GENDER (M/F) DATE OF BIRTH ( PHYSICIAN/PROVIDER ADDRESS AGE ) ZIP IF UNDER 18, WEIGHT PHYSICIAN/PROVIDER PHONE Yes Please answer the following questions to determine if you are eligible to receive a vaccination today. 1. Which vaccines* are you requesting to have administered today? Please check all requested vaccines. Inactivated Influenza (Flu) Pneumonia Shingles Tdap (Whooping Cough) Don t No Know Other: Y N ? Y N ? 4. Ha.

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