Epstein Secrets

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

DTaP is an acceptable alternative for one or more doses 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 thir

• (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

d. Mal is an acceptable alternative for one or moredoses 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 do

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

DTaP is an acceptable alternative for one or more doses 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 thir

. 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

DTaP is an acceptable alternative for one or more doses 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 d

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

DTaP is an acceptable alternative for one or more doses 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 thir

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

DTaP is an acceptable alternative for one or more 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 or older. Polio 4 doses required. If the third d