+ 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 If yes, estimated date: C No HEP B 0 Yes If yes, estimated date: ❑ No 170 East 77th Street. New York. NY 10075 EFTA00314174