IMMUNIZATION CLINIC Patient Intake Form PATIENT INFORMATION NAME DATE OF BIRTH ADDRESS PHONE ANY KNOWN FOOD OR DRUG ALLERGIES INSURANCE INFORMATION INSURANCE COMPANY ID NUMBER GROUP NUMBER BIN NUMBER PCN NUMBER ☐ Medicare ☐ Medicare Advantage VACCINES...
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IMMUNIZATION CLINIC Patient Intake Form PATIENT INFORMATION NAME DATE OF BIRTH ADDRESS PHONE ANY KNOWN FOOD OR DRUG ALLERGIES INSURANCE INFORMATION INSURANCE COMPANY ID NUMBER GROUP NUMBER BIN NUMBER PCN NUMBER ☐ Medicare ☐ Medicare Advantage VACCINES REQUESTED ☐ ☐ Infuenza (Flu) ☐ Shingles Pneumonia ☐ RSV ☐ Tdap (Tetanus) PATIENT / GUARDIAN SIGNATURE DATE
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