• Do you want the above referenced patient to receive the flu vaccination?
  • Has the above referenced patient ever had a severe reaction to a previous vaccination including neurological (nerve or muscle) complications to your knowledge?
  • Does the above referenced patient have an allergy to eggs?*

  • Please review the CDC Influenza information attached or at the CDC website link at: https://www.cdc.gov/flu/prevent/keyfacts.htm



  • Date
     / /
  •  
  • Should be Empty: