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Preferred Pharmacy
Birthday
Have you had a high temperature or fever in the last 24hrs?
Yes
No
Have you ever had an allergic or anaphylactic reaction to an influenza vaccine or any other vaccine before?
Yes
No
Do you have any allergies?
Women only: Are you pregnant, or is there any possibility that you could be pregnant?
Women only: Are you currently breast-feeding?
Yes
No
Are you immunosuppressed due to disease or treatment?
Yes
No
Do you have a bleeding disorder, including taking any medication that thins your blood (anticoagulants)?
Yes
No
Are you likely to come into close contact with severely immunocompromised patients?
Yes
No
Do you feel any stress related reactions (e.g. feeling faint) when receiving a vaccine?
Yes
No

Please confirm the following statements.

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