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E: Home Phone: Mobile Phone: Male Female Date of Birth Email: (MM/DD/YYYY): Age: Kg Child s Weight: lb Emergency Contact Name: By provincial legislation, Pharmacists cannot administer a flu shot to children under a certain age. Ask your pharmacist for age restrictions. Emergency Contact s Relationship to Patient: Contact s Phone Number: Flu Vaccine Questionnaire Yes No Notes Do you or have you had a fever within the past 3 days? Have you ever had an allergic reaction to.

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