AMC COVID Booster/ influenza vaccine

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* 1. Full name of patient

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* 2. Current age

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* 3. Date of birth

Date

Date

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* 4. Best contact number

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* 5. Administration preference

Would rather COVID booster and Influenza vaccines together (convenience - happy to wait)

Would rather have my COVID booster and Influenza vaccines separately (soonest possible for both)

I only want the COVID booster vaccine

I only want the Influenza vaccine

I wish to decline both COVID booster and Influenza vaccines