Flu Form

Consent / Declination for Influenza Vaccination

* Indicates required field

Name *

First

Last

Email *

Do you have a SEVERE allergy to eggs or other vaccine components? *

Yes No

Have you ever had Guillain-Barre Syndrome within 6 weeks after a previous influenza vaccination? *

Yes No

Vaccination Status: *

If vaccinated at another location, please provide the location name and date of vaccination: *

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