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University of Virginia Nelson Department of Student Health PO Box 800760 Charlottesville VA 22908 434-982-3915 (Trap) Diphtheria, tetanus and pertussis are serious diseases caused by bacteria. With
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Begin by reading the instructions carefully to understand the purpose and requirements of the form.
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This form is typically required for students or staff members of the University of [University name] who wish to receive the vaccine.
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