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徐嘉賢診所-新冠肺炎疫苗候補/殘劑登記單
此為新冠肺炎疫苗「候補」登記單,如果診所遇到臨時有人取消,將隨時通知,依序施打。
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姓名(接種者)
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聯絡電話(請務必聯絡得到)
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出生年月日(請務必填寫身分證上的出生年月日)
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例如民國50年1月2號,請輸入: 500102
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身份證字號(接種者)
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地址
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其他聯絡人姓名,例:陪同者,家人,子女(如有)
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聯絡人電話號碼(如有)
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