| Document Date: 2014-07-23 14:29:37
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Company United Supermarkets LLC / / Facility No No F Yes No No Store / / MedicalCondition Inactivated Polio / allergy / fever / Meningitis Oral Typhoid / Typhoid / vomiting / pneumonia / Cancer / HIV / COPD / AIDS / Flu / Yellow Fever / Shingles / diarrhea / Hepatitis A/B / HPV / Flumist TB skin test Pneumonia / rheumatoid arthritis / chronic / Varicella / nausea / Tetanus / Heart Disease / Chronic Bronchitis / Diabetes / Yes Please Specify allergy / hepatitis B / Asthma / / MedicalTreatment immunization / vaccinations / radiation treatments / chemotherapy / Organ transplant / / Organization MEDICARE / / Position Physician / Team Member / / Product Tamiflu / Plavix / Valtrex / Famvir / ibuprofen / acyclovir / / Technology radiation / chemotherapy / /
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Microsoft Word - Immunization Consent Form 2011