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/ Td 7 yrs. Tdap Booster Haemophilus influenza Type b Hib Hepatitis B HepB Polio IPV OPV Measles Mumps Rubella MMR Measles Mumps Rubella Varicella Chicken Pox Disease History Yes When Month Year Verified by Health Care Provider Name Title Pneumococcal Conjugate Meningococcal Vaccine Human Papillomavirus HPV Influenza Recommended Rotavirus Recommended Other Signature of Medical Provider Print Name or Stamp Section 2 MEDICAL EXEMPTION. For Health Care Provider Use Only. The facility will also...
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