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Get Screening Form for Adult Immunization: Pneumococcal Tdap or Zoster Vaccine 2013-2024

Female Address: ________________________________________________________________________________ Street Phone: ( City ) ________________ State Zip Doctor’s Name & Clinic: ___________________________________ PLEASE ANSWER THE FOLLOWING QUESTIONS BEFORE RECEIVING YOUR VACCINE: 1. Are you sick today? 2. Do you have allergies to medications, food, any vaccine, gelatin, neomycin, or latex? A 3. Have you ever had a serious reaction after receiving a vaccination? B 4. Do you have cancer, leuk.

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