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25 mL Sanofi Pasteur Lot UT5598LA FOR PATIENTS 6 months 35 months old Exp 6/30/17 NDC 49281-516-00 Lot UT5663KA Lot UT5673KA NDC 49281-416-50 FOR PATIENTS 3 years old Lot U5587BA NDC 49281-416-58 RN/LPN/MA Signature Site Date Form 5865 Revised 10/16 HIM Approval 10/15. I authorize the Recipients and the Department to use the Immunization Records that will be maintained in the Immunization Registry to provide immunization services to my child to monitor my child s immunization status to...
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