Imes Pharmacy Vaccination Pre-Screening Form
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Name of person completing this form if completing on behalf of someone else
Name of Person to be Vaccinated (as per Medicare card) *
Patient's Date of Birth *
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DD
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YYYY
Patient's Gender *
Patient's Estimated Weight *
Patient's Address *
Patient's Allergies (if none, type N/A) *
Patient's Phone Number *
Patient's Medicare Card Number (Including reference number) *
Patient's Medicare Card Expiry *
MM
/
DD
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