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Flu Shot Questionnaire Form
Free with most insurances
17Questions
  • 1
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    Enter
  • 2
    MM/DD/YYYY
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  • 3
    For appointment confirmation & directions.
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  • 4
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  • 5
    If yes, the pharmacist will ask you in detail
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  • 6
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  • 7
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  • 8
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  • 9
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  • 10
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  • 11
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  • 12
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  • 13
    If not applicable, please select No
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  • 14
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  • 15
    Ex: Driver License, Military ID, Passport
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  • 16
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  • 17
    Clear
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  • Should be Empty:
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