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School Shots for Adolescents 07-30-20
This form is to sign your student up to be immunized on THURSDAY, JULY 30TH for required and recommended vaccinations before the school year.  
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Email *
LAST NAME OF STUDENT *
FIRST NAME AND MIDDLE INITIAL OF STUDENT *
SEX *
DATE OF BIRTH *
STREET ADDRESS *
CITY *
ZIP CODE *
BEST PHONE NUMBER *
AGE OF STUDENT *
FORM COMPLETED BY/RELATIONSHIP TO CHILD *
INSURANCE INFORMATION *
PRIVATE INSURANCE COMPANY
PRIVATE INSURANCE POLICY NUMBER
PRIVATE INSURANCE GROUP NUMBER
PRIVATE INSURANCE POLICY HOLDER
PRIVATE INSURANCE POLICY HOLDER DATE OF BIRTH
RACE *
VACCINATIONS  TO BE GIVEN *
Required
IS THE CHILD SICK TODAY? (PLEASE UPDATE ON SHOT DAY) *
DOES YOUR TEEN HAVE ALLERGIES TO A VACCINE COMPONENT, OR TO LATEX? *
HAS YOUR TEEN EVER HAD A SERIOUS REACTION TO A VACCINE IN THE PAST? *
HAS YOUR TEEN HAD BRAIN OR OTHER NERVOUS SYSTEM PROBLEMS? *
ADOLESCENT FEMALES: IS TEEN PREGNANT? *
APPOINTMENT TIME *
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