Influenza/Pneumococcal Immunization Record
Site/Clinic Location: Influenza / pneumococcal Immunization Record Last Name First Name Initial Gender Provincial Health Care Number/ULI Age Date of Birth (yyyy-Mon-dd). Alberta Address Phone (Home). City Province Postal Code Phone (Other). Out of Province Address (if applicable) Province Status: New to Alberta Visitor Influenza Vaccine Informed Consent Vaccine (Manufacturer): Priority List by Reason Code: Fluzone (SF) mL IM Lot # _________________. 03 Health care worker FluLaval (GSK) mL IM Lot # _________________. Other _________________ Lot # _________________.
09826(Rev2018-06) Site/Clinic Location: Infl uenza/Pneumococcal Immunization Record Last Name First Name Initial Gender Provincial Health Care Number/ULI Age Date of Birth (yyyy-Mon-dd) Alberta Address Phone (Home)
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