Epstein Secrets

nical reasoning or evidence for exemption: DOE Code 3 I cent& that the physical condition of this child is such that immunizations) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: DII 450, Pd2000, obsoletes whet

nic Name: (Print or stamp) Expiration Date: (t5 days after next immunization appointment) Physician or Address: Authorized Signature: Date: Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 I c

cal reasoning or evidence for exemption: DOE Code 3 I certify that he physical condition of this child is such that immunization(s) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Address. Physician Signature. DN 680, &NS repbces earlier ed

• (Print or Stamp) Address: Expirati0n Date' _Olitlazufttstualimaadzatisin atipSathunD *LI Physician or Authorized Signature. Date. Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 I c

nical reasoning or evidence for exemption. DOE Code 3 1 cent that the physical condition of this child is such that immunization(s) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: DH 680, 8/2000, obsoktm tallitt

rvice Address: Riviera Bea L 33404 Phone: Expiration Date: (IS days after next Physician or Authorized Signatu A. 41/21-4goo/ w 7 3.0) •, Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 / c