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Get NY DOH-4156 2010

N ≥ 19 Years Old Clinic/Office Site Where Vaccine Administered Policy Number No No Sex No Are you (your child) currently sick with a fever? Do you (your child) have a severe allergy to eggs, latex or an ingredient of the flu or pneumococcal vaccine? If yes, which? Have you (your child) ever had Guillain Barré syndrome? Is this your (your child’s) first time getting the flu vaccine? Have you (your child) had any vaccine within the last 28 days? If yes, which vaccine? Date? Have you eve.

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