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VACCINE ADMINISTRATION CONSENT FORM BROOKSHIRE GROCERY COMPANY; ENGLISH VERSION (rev 08/11/2020) Date of Birth: Patient Name: City:Address: Primary Doctor: Fax #: PLEASE ANSWER THE FOLLOWING QUESTIONS: __Yes __Yes __Yes __Yes__No __No __No __No__Yes __Yes__No __No__Yes__No__Yes__No__Yes __Yes __Yes__No __No __Vaccine(s)

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A city is a large human settlement that is typically characterized by significant infrastructure, a high population density, and various services provided to its inhabitants.

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