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Signature Date Below Section to be completed by Healthcare Provider I certify that the above patient is under my medical care and should be exempt from receiving the influenza vaccination due to medical reason s noted below Recognized contraindication to influenza vaccination please mark all that apply and include dates of reaction if known Severe allergic reaction to eggs. Wrong and request a religious exemption based on the following reason Submit the completed Seasonal Influenza Vaccine...

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Front desk 608-263-5202 is the main contact number for the front desk at the specified location.

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