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Record the Month. Day and Year that each Dose of Vaccine was Received Vaccine 1st 2nd 3rd 4th 5th 6th Diphtheria Tetanus Pertussis DTaP Poliomyelitis IPV/OPV Measles Mumps Rubella MMR Hepatitis B HepB Hx of Disease Physician Signature Varicella VAR Date of Illness Hemophilus Influenzae Type B Hib Pneumococcal Conjugate PCV Rotavirus Recommended 8 mo of age not required Influenza Flu Recommended annually 6 mo of age not required Section II. Please either A requiring or B below and K. S.A....
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