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INFLUENZA VACCINE CONSENT FORM Patients Name:Date of Birth:MAN# 1. Have you ever had an allergic reaction to flu vaccine? Yes or No2. Are you allergic to eggs, or egg product? Yes or No3. Do you have
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01
Download the SSM Health Medical Group Influenza Vaccine Consent Form (STL) from the official website.
02
Read and understand all the instructions and information provided on the form.
03
Fill out your personal information accurately, including your name, date of birth, and address.
04
Provide your contact information, such as phone number and email address, if required.
05
Answer all the medical history questions honestly and thoroughly.
06
If you have any specific allergies or medical conditions, make sure to mention them in the appropriate section.
07
Indicate whether you have previously received the influenza vaccine and provide the date if applicable.
08
Review the form to ensure all the necessary fields are filled out correctly.
09
Sign and date the consent form to acknowledge your agreement and understanding.
10
Submit the completed form to the designated healthcare provider or facility.

Who needs ssm-health-medical-group-influenza-vaccine-consent-form-stl?

01
Anyone who wishes to receive the SSM Health Medical Group Influenza Vaccine in St. Louis (STL) needs to fill out the consent form. This applies to both new patients and established patients of the medical group. It is important for individuals of all ages who want to receive the influenza vaccine to complete this form to ensure proper documentation and understanding of the vaccination process.
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The SSM Health Medical Group Influenza Vaccine Consent Form STL is a document that allows patients to provide consent for receiving the influenza vaccine administered by SSM Health Medical Group.
Patients who wish to receive the influenza vaccine through SSM Health Medical Group are required to fill out and file the consent form.
To fill out the form, you need to provide personal information, medical history, and any allergies, then sign the form to grant consent for the vaccine.
The purpose of the form is to ensure that patients are informed about the influenza vaccine and to obtain their consent for its administration.
The form typically requires personal identification information, vaccination history, allergies, and consent signatures.
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