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Get Walgreens 12FL0001 2012

E Female Last Name City State ZIP Code Email Address Medicare Part B Number (if applicable) Primary Care Physician/Provider Name (if known) Physician/Provider Phone Physician/Provider Address City State SECTION B The following questions will help us determine your eligibility to be vaccinated today. YES NO DON’T KNOW 1. Which vaccines are you requesting to have administered today? Please check all requested vaccines: Flu Shot Flu Nasal Spray (live — ages 2–49 only) Flu HD.

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