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CHILD 2022/2023 Influenza Vaccine Consent Cedar County Public Health×400 Cedar St. Lipton, IA*(563) 8862226 PATIENT INFORMATION LAST NAME:FIRST NAME:MIDDLE INITIAL:GENDER (circle one):Male DATE OF
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Obtain a copy of the Cedar County Public Health 400 form.
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Submit the completed form to the Cedar County Public Health office.

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Cedar County Public Health400 is a form used to report public health information.
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