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FOR OFFICE USE ONLY Temp:___ COVID-19 S/S: ___ Known Exposure to COVID-19: ___INFLUENZA VACCINE CONSENT FORM Rebirth Date/Today's Date/Address City/State Telephone NumberS ex (M/F)Primary Policyholders

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How to fill out influenzapneumococcal

01

Step 1: Obtain the influenzapneumococcal form from a healthcare provider or pharmacy.

02

Step 2: Read and understand the instructions provided with the form.

03

Step 3: Fill in your personal information such as your name, date of birth, and contact information.

04

Step 4: Provide your medical history, including any relevant conditions or allergies.

05

Step 5: Specify your vaccination preferences, such as the type of vaccine or any specific instructions.

06

Step 6: Sign and date the form to verify that the information provided is accurate and complete.

07

Step 7: Return the completed form to the healthcare provider or pharmacy as instructed.

Who needs influenzapneumococcal?

01

Individuals aged 6 months and older are recommended to get influenzapneumococcal vaccination, particularly individuals at higher risk of developing severe complications from influenza or pneumococcal infections.

02

This includes but is not limited to: children, pregnant women, older adults, individuals with chronic medical conditions (such as asthma, diabetes, heart disease), healthcare workers, and individuals living in long-term care facilities.

03

It is advisable to consult with a healthcare provider to determine if you or someone you know should receive influenzapneumococcal vaccination.

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What is influenzapneumococcal?

Influenzapneumococcal is a combination vaccine that helps protect against both influenza (flu) and pneumococcal diseases.

Who is required to file influenzapneumococcal?

Healthcare providers and facilities are required to file influenzapneumococcal for their patients.

How to fill out influenzapneumococcal?

Influenzapneumococcal can be filled out by healthcare providers following the guidelines provided by the CDC.

What is the purpose of influenzapneumococcal?

The purpose of influenzapneumococcal is to prevent influenza and pneumococcal diseases in patients.

What information must be reported on influenzapneumococcal?

Influenzapneumococcal must include patient demographics, vaccination dates, and any adverse reactions.

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