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Questionnaire for Influenza
Are you taking Oseltamivir to treat current flu symptoms? Required
Are you between 18 and 65? Required
Are you currently breastfeeding, pregnant or planning to become pregnant in the next six months ? Required
Do you have any known allergies or adverse reaction to any medications? Example: Egg Allergies Required
Have you been experined any of the following? Required
Have you been exposed to any one that has influenza? Required
Are you currently taking any medication? This includes over the counter, prescription medications and/or recreational drugs. Required
Do you agree with the folllowing statement below? Required

Please contact us if you experienced side effects from the treatment, start new medication or
develop or have a change in your medical condition.


The treatment is solely for you in your own use.


You understand the healthcare provider takes your answers in good faith and base their treatment
on decisions accordingly, and that incorrect information can be hazardous to your health.


You will read the patient information leaflet supply with your medication.


You will notify your primary care physician about your treatment from PBJ medical associates.

Thanks. We'll get back to you soon.

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7380 West Sand Lake Road

Orlando, FL 32819

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​CONTACT US

(800) 485-7962
info@pbjmedicalrx.com

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