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Patient Information Form – Flu Vaccine

Please fill out the below information for each patient, select a store, and then press submit. We request that you come into your selected pharmacy within 10 days of submitting this form in order to help our pharmacy team plan and prepare for you.

  • Please enter all patients.
    First Name Last Name  
       
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Let The Gifting Begin!

It’s the season of giving, and Bartell’s is here to make your holiday shopping easy and FUN this year.

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