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Vaccination History Form
Covid-19 and Influenza
This information will be kept confidential and in accordance with privacy laws and regulations
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Name
*
First
Last
Email
*
Have you had COVID-19 vaccinations?
Yes
No
Date of First Dose
Date of Second Dose
Date of Booster Dose (copy)
Have you had Influenza Vaccine?
Yes
No
Date of Vaccination
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*
My inputs are Accurate
Submit
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