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PRIORITY PRIVATE CARE
ALLERGIES
Do you have any allergies or known reactions to foods, latex and
medications?
List all allergies and reactions
VACCINATIONS
Have you had the following vaccinations?
TETANUS
If yes, estimated
HEP A ❑ Yes C No
If yes, estimated date:
HEP B 0 Yes ❑ No
If yes, estimated date:
170 East 77th Street. New York. NY 10075
EFTA00314174
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