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How to use or fill out New York Putnam County Influenza Immunization Consent Form
- Click ‘Get Form’ to open it in the editor.
- Begin by entering your name and date of birth in the designated fields. Ensure that all information is accurate for proper identification.
- Fill in your address, city, state, and zip code. This information helps in maintaining accurate records.
- Select your sex by checking either 'Male' or 'Female'.
- Provide your phone number for any follow-up communication regarding the vaccination.
- Enter your doctor’s name and address if applicable, along with your Medicare Claim Number if you are using Medicare.
- Answer the health-related questions regarding fever, previous flu shots, allergies, pregnancy status, and Guillain Barre syndrome by selecting 'Yes' or 'No'.
- Read the consent statement carefully. If you agree, sign and date at the bottom of the form.
- Leave the area below for completion by a nurse after vaccination. This includes details about the vaccine administered.
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