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Get UT Influenza Vaccine Consent Form and Administration Record

________________________________________ SEX: M F CITY: ________________________________ STATE: ___________ ZIP: _____________ I have read or have had explained to me the Vaccine Information Statement about influenza and the influenza vaccine. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the influenza vaccine and ask that the vaccine be given to me or the person named above for whom I am authorized to make this req.

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