+ 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 HEPA 0 Yes 0 No If yes, estimated date: HEP B O Yes 0 No If yes, estimated date: 170 East 77th Street, New York, NY 10075 FY EFTA00314174