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Report of Anaphlaxyis with Use of Epinephrine Injector
Name of business:
*
Type of business
*
Agriculture
Colleges and Camps
Domestic Services
Education and Learning
Entertainment
Hair and Beauty
Manufacturing
Medical
Pets
Retail shopping
Restaurant
Sports and Recreation
Other
Other
Information About Person Reporting
Last Name
*
First name
*
Title
*
Phone number:
*
Email address:
*
Are you the same person who administered the epinephrine?
*
Yes
No