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Rains Pharmacy Vaccine Consent Form
Are you 65 or older?
Vaccine Requested
Insurance Coverage
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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