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East Valley Vaccination and Examination Center |




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Initials |
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ASIIS# NE AHCCCS uninsured underinsured NA KC
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List All Medicines you are allergic to along with the reaction you had to that medication (If more room needed, please use back of form) |
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List All Medications you are currently taking ( including how much). (If more room needed, please use back of form) |
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Medicine Allergy |
Reaction |
Medicine Allergy |
Reaction |
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Medication |
Dose |
Medication |
Dose |
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