Epstein Secrets

es of DTP. 3 DT (pediatric) is acceptable if Pertussis vaccine is medically contraindicated. (Complete Part C for Pertussis contraindication.) 4 Td (Adult) Vaccine is recommended for children 7 years of age or older. 5 Polio 4 doses required. If the third dose is administered on or after the fourth birthday, a

sician or Clinic Name: (Print or stamp) Address: Expiration Date: (15 days after ant inuntuthafteei appointment) hvsician or ignature: Date: Permanent Medical Exemption PART C For medically contraindicated immun exemption: DOE Code 3 tions, list each vaccine and state valid clinical reasoning or evidence for I ce

doses of DTP. 3 DT (pediatric) is acceptable if Pertussis vaccine is medically contraindicated. (Complete Part C for Pertussis contraindication.) Td (Adult) Vaccine is recommended for children 7 years of age orolder. $ Polio 4 doses required. If the third dose is administered on or after the fourth birthday, a

• (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

es of DTP. 3 DT (pediatric) is acceptable if Pertussis vaccine is medically contraindicated. (Complete Part C for Pertussis contraindication.) 4 Td (Adult) Vaccine is recommended for children 7 years of age or older. 5 Polio 4 doses required. If the third dose is administered on or after the fourth birthday, a

his time. Physician or Clinic Name: (Print or stamp) 14 ,.- .-;.pmnrsitio iWn vate*s it 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

es of DTP. 3 DT (pediatric) is acceptable if Pertussis vaccine is medically contraindicated. (Complete Part C for Pertussis contraindication.) 4 Td (Adult) Vaccine is recommended for children 7 years of age or older. Polio 4 doses required. If the third dose is administered on or after the fourth birthday, a fo

. Physician or Clinic Name: (Print or stamp) Address: xpirAtion ate osaasiltroexibmigilitkitiir 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

es of DTP. 3 DT (pediatric) is acceptable if Pertussis vaccine is medically contraindicated. (Complete Part C for Pertussis contraindication.) 4 Td (Adult) Vaccine is recommended for children 7 years of age or older. s Polio 4 doses required. If the third dose is administered on or after the fourth birthday, a

an or Clinic Name: (Print or stamp) Address: Expiration Date: (r9 dart after nest humanization appo 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

ses of DTP. s DT (pediatric) is acceptable if Pertussis vaccine is medically contraindicated (Complete Part C for Pertussis contraindication ) ▪ Td (Adult) Vaccine is recommended for children 7 years of age or older. Polio 4 doses required. If the third dose is administered on or after the fourth birthday, a fo

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