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NPI: 1326132218INFLUENZA VACCINE 20162017 HEALTH SCREEN & PERMISSION FORM Full Name:Date of Birth:/ Street Address: Grade:School Name: Age:/Town/City:Gender: M F Zip Code:Teacher:Daytime Phone:School
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How to fill out flu 12016-17 intake form
How to fill out flu 12016-17 intake form
01
Begin by filling out your personal information, including your full name, date of birth, address, and contact information.
02
Next, provide information about your medical history, including any chronic conditions or allergies you may have.
03
Indicate whether or not you have received a flu shot in the past, and if so, provide the date of your last vaccination.
04
Answer any additional questions regarding your current health status, such as whether or not you are currently experiencing any flu-like symptoms.
05
Finally, sign and date the form to indicate that all the information you provided is accurate and complete.
Who needs flu 12016-17 intake form?
01
Anyone who is planning to receive the flu vaccine for the 2016-17 flu season needs to fill out the flu 12016-17 intake form. This form helps healthcare providers assess your eligibility and identify any potential contraindications or allergies that may affect the administration of the vaccine.
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What is flu 12016-17 intake form?
The FLU 12016-17 intake form is a document used by taxpayers to report specific tax information related to the tax year 2016-2017, such as income, deductions, and credits.
Who is required to file flu 12016-17 intake form?
Individuals or entities who have taxable income or deductions that need to be reported for the tax year 2016-2017 are required to file the FLU 12016-17 intake form.
How to fill out flu 12016-17 intake form?
To fill out the FLU 12016-17 intake form, you need to gather your financial documents, enter your personal information, report your income, deductions, and any applicable credits, then review and submit the form according to the instructions provided.
What is the purpose of flu 12016-17 intake form?
The purpose of the FLU 12016-17 intake form is to facilitate the accurate reporting of income and deductions for tax purposes, ensuring compliance with tax regulations for the 2016-2017 tax period.
What information must be reported on flu 12016-17 intake form?
The FLU 12016-17 intake form must report information such as your name, address, Social Security number, income details, losses, deductions, and any tax credits.
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