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  • Wegmans Pharmacy Informed Consent/screening Questionnaire To Receive Inactivated Injectable

Get Wegmans Pharmacy Informed Consent/screening Questionnaire To Receive Inactivated Injectable

Wegmans Pharmacy Informed Consent/Screening Questionnaire to Receive Inactivated Injectable Influenza Vaccine (NY) Name: Date of Birth: Age: mm/dd/yyGender: Local Phone # Local Address: City State:.

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Influenza vaccination is contraindicated for individuals who have had documented anaphylaxis to any ingredient in the vaccine or to a previous dose of inactivated influenza vaccine.

Has the person to be vaccinated ever received a dose of COVID-19 vaccine? If yes, which vaccine product was administered? How many doses of COVID-19 vaccine were administered? Did you bring the vaccination record card or other documentation?

The U.S. Centers for Disease Control and Prevention (CDC) recommends routine vaccination to prevent vaccine-preventable diseases that occur in infants, children, adolescents, and adults. Screenings are medical tests that doctors use to check for certain disorders before there are any symptoms.

Some of the most common invalid contraindications are mild illnesses, pregnancy, breastfeeding, allergies that are not anaphylactic in nature, and certain aspects of the patient's family history.

Would a monetary incentive offered by [Company name] change your mind? Would another type of incentive offered by [Company name], such as paid time off, change your mind? Do you have a medical reason for not receiving the COVID-19 vaccine? Do you have a religious objection to receiving the COVID-19 vaccine?

What's a VIS? A VIS or Vaccine Information Statement is a document, produced by CDC, that informs vaccine recipients – or their parents or legal representatives – about the benefits and risks of a vaccine they are receiving.

If a question is not clear, please ask your healthcare provider to explain it. No. ... Is the person to be vaccinated sick today? Does the person to be vaccinated have an allergy to eggs or to a component of the vaccine? Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232