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Rains Pharmacy Vaccine Consent Form
Are you 65 or older?
Sex
Would you like a B12 shot as well? They're $25 if not covered by insurance.
Are you feeling sick today?
Do you have any allergies to any medications, food (egg products), or vaccines?
Have yo ever fainted or had a serious reaction to a vaccine?
Are you pregnant or likely to become pregnant in the next 3 months?
Do you have cancer, AIDS, or any other immune system problems?
Do you currently take any oral steroids, anti-cancer meds, radiation, or immune suppressing medicatinons?
In the last year, have you received a blood transfusion, plasma, or immunoglobulin?
Do you havea brain disorder or suffer from seizures?
Have you received any vaccinations in the last 4 weeks?
Have you received TB skin test in the last week?

Successful! See you there!

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