GPS Flu Vaccine Registration - Adult Logo
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  • Seasonal Influenza Vaccine Consent Form

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  • PERSONAL INFORMATION

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  • INSURANCE INFORMATION

  • *Please bring your insurance card with you at the time of service, OR attach a copy of your prescription insurance card.

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  • PRIMARY

  • SECONDARY

  • *Please bring your insurance card with you at the time of service, OR attach a copy of your prescription insurance card.

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  • This does not gaurantee we will have in stock, or be able to give additional vaccines. 

  • Screening Checklist for Contraindications to Vaccines for Adults

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  • The following questions will help us determine which vaccines you may be given today. If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked.  If a question is not clear, please as your healthcare provider to explain it. 

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