Flu Vaccine Registration Form

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33% of survey complete.

Please fill out the information below to receive your annual influenza vaccine:

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* 1. Patient Name:

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* 2. Date:

Select date

Date

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* 3. Sex:

F

M

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* 4. DOB:

Date of Birth

Date

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* 5. Age:

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* 6. Phone:

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* 7. Address:

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* 8. City:

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* 9. State:

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* 10. Zip:

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* 11. What is your race/ethnicity?

White

Black/African-American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Other