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Get Rite Aid Pharmacy Screening Questionnaire Consent and Physician Fax Form 2012-2024

______________________*Date of Birth: _________ *Age: _____ *Phone# _________________ *Address: _______________________________ *City: ___________________________ *State: _____ *Zip:_________ *Gender: M or F *Which vaccine(s) would you like to receive today? _________________________________________ *Medical Conditions: ___________________________________________ *Enter Weight if less than 110 lbs: ________ **FOR EMERGENCY USE ONLY** *Primary Doctor: _________________________________ *Dr. Phone.

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