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Get WA GroupHealth DA-2776 2015-2024

R “yes” to any of these questions, or don’t know the answer, please don’t sign this form without talking to your doctor or nurse. Please read the Vaccine Information Statements (VIS) we gave you for the vaccine you are getting today. Influenza Vaccine Card / Sticker Yes No yy this person had a serious (life-threatening) allergic reaction to any previous dose of the vaccine(s) Has or vaccine components? .

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