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_____ i do not want a flu shot i acknowledge that i am aware of the. Please check all that apply. Web signature date name (print) department reference: Prevention and control of seasonal influenza with vaccines: Web seasonal influenza vaccine declination form print name:
Web (see back) have read and fully understand the information on this declination form. Web seasonal influenza vaccine declination form print name: Medical reason severe allergies to eggs, severe allergy vaccine. Please check all that apply. Web decline vaccination for the one of the following justified reason(s). _____ i do not want a flu shot i acknowledge that i am aware of the. Prevention and control of seasonal influenza with vaccines: Web signature date name (print) department reference:
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Please check all that apply. Web signature date name (print) department reference: _____ i do not want a flu shot i acknowledge that i am aware of the. Web decline vaccination for the one of the following justified reason(s).
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Web (see back) have read and fully understand the information on this declination form. Medical reason severe allergies to eggs, severe allergy vaccine.