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Rubella Varicella Chickenpox Meningococcal conjugate MCV4 RECOMMENDED BUT NOT REQUIRED Vaccine / Dose HPV Influenza Other Specify Immunization Administered/Dates Health care provider MD DO APN PA school health professional health official verifying above immunization history must sign below. The mo/da/yr for every dose administered is required. If a specific vaccine is medically contraindicated a separate written statement must be attached by the health care provider responsible for...
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