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OUTS College of Pharmacy 1110 N. Stonewall Avenue, Oklahoma City, OK 73117 Influenza Immunization Program 2015 2016 Have you ever received an influenza (flu) vaccination? Have you ever had a severe
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Start by carefully reading the instructions provided on the form.
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Write your full name and contact information in the specified fields.
03
Provide your date of birth and any other personal identification details requested.
04
Indicate the date of immunization and the type of vaccine received.
05
Specify the name and address of the healthcare professional or clinic that administered the immunization.
06
Sign and date the consent form to acknowledge your agreement and authorization.
07
If applicable, provide any additional information or notes requested.
The 1immunization consent-oucop2014 inactivatedapproved9-4-15 is typically required by individuals who have undergone or are planning to undergo an immunization procedure. This consent form ensures that the individual consents to the administration of the vaccine and grants permission to the healthcare professional or clinic to carry out the immunization. It may be required by healthcare facilities, educational institutions, or employers to maintain proper records and ensure compliance with immunization requirements. It is important to check with the specific organization or entity requesting the form to confirm who needs to fill it out.
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This form is a consent form for inactivated immunization approved on September 4, 2015.
Healthcare providers administering inactivated immunizations.
Fill out the form with all required information and obtain necessary signatures.
The purpose is to document consent for inactivated immunization administration.
Patient's personal information, type of inactivated immunization, date of administration, healthcare provider information.
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