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5 ml LAIV Manufacturer Lot Number VIS Date Nurse Signature Next Immunization Due DOH-4156 6/14 Next Year In 4 Weeks Other Immunizer White Provider Yellow Patient Pink None Needed. NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Immunization Influenza/Pneumococcal Immunization Consent Form Name Please Print Date of Birth Sex County of Residence Address City Phone For Persons Under 19 Years Old Mother s Maiden Name...
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