| 1. Is this person allergic to Doxycycline, Tetracycline or any other 'cycline' drug? |
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| 1a. Has person experienced respiratory (breathing) or cardiac (heart) arrest after taking this medication? |
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| 2. Is this person allergic to Ciprofloxacin or any other “floxacin” drug? |
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| 2a. Has person experienced respiratory (breathing) or cardiac (heart) arrest after taking this medication? |
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| 3. Does this person have an allergy to amoxicillin? |
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| 4. Does this person have seizure disorder or epilepsy? |
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| 5. Is this person taking Tizanidine (Zanaflex ©)? |
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| 6. Does this person have difficulty swallowing pills? |
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| 7. Does this person have renal (kidney) disease or Myasthenia Gravis? |
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| 8. Is this person immunocompromised (AIDS)? |
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| 9. Has this person experienced an adverse reaction to AVA vaccine? |
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| 10. Is this person pregnant? |
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I, the undersigned, certify that all of the above information
is correct to the best of my knowledge. I hereby authorize the recipient of this
document to share this information with public health entities at the local, state and federal
level for purposes of ensuring medication efficacy and safety. I have been offered a copy of the Vaccine Information
Statement(s)(VIS) for AVA. I have read, had explained to me, and understand the information on the VIS(s).
I ask that the vaccine(s) be given to me or to the person named for whom I am authorized to make this request
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