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Parent/Guardian Signature Page 1 PART II IMMUNIZATIONS Entire section below to be completed by MD/DO/APN/NP/PA Printed VAR form may be attached in lieu of completion. DTaP/ DT / / OPV/ IPV PCV7/ PCV13 Hib MMR VAR MCV4 Hep A / Influenza HepB /HepB-2 RV-2/ RV-3 HPV Td/ Tdap PPSV23 Child is fully immunized per DPH/CDC recommendations refer to cover page HepB RV-3 Td PART III SCREENING TESTING Tuberculosis Screen Dental Height Weight BMI BMI Percentile BP Pulse Other inches pounds Problem...

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