Epstein Secrets

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

ALTH HISTORY (Serious Illnesses Inures explain) (attach narrative it additonal space needed) C. I ARARATARY Ina inelinlaelli e Tuberculin test Sickle Cell type date result NAME: TITLE: ADDRESS: (Please Print) r-rdl- OH 3040. 10116 (lieplooli 14R5-14 Form 3040 which easy be used) Mock Plumbot. 5

ic (Print or Stamp) Add ACES, FLORIDA 33401 days after next Immunization appointment) Physician or Authorized Slgnat ed a schedule to I t o Permanent Medical Exemption PART C For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption: DOE Code 3 cer

ir (attach narratrve if additional space needed) C. LABORATORY (a, indicate) Hempeiptyin/Hernatocrir Stool (O & P) Tuberculin test Leao Sickle Cell type date results NAME: FAMit y talee rtrn -ra TITLE: TV) P . CENTER Ntint atii J. ADDRESS: Royal Palm Beach, F/ 57) 7 95. 4773 (P

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

n) (attach narrative d additional space needed) C. LABORATORY (as indicated) t- rnoglcbin/Hemafocrit Stool (O & Tuberculin test: LP 1C1 Sickle Cell d NAME: TITLE: ADDRESS: (Please Print) 1 7A /7 5 OH 3040. 10/16 (Rapacas HRS-ef Form 3040 when may 0* oseie) (Stock Nwnbsr 57444430 JU0 2)

ic Name: 05•days after next immuilization.appoiutrnent) (Print or stamp) . . _ . . . • 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

Illnesses Injuries: explain) (attach narrative it additional space needed) C. LABORATORY Hemoglobin/Hematocrit Stool 1O & P) Tuberculin test: Sickle Cell Lead Authorized Signature OH 3040. 10190 (Replaces NRS-li Form 3040 which may be used) (Slack Number 5741-000-3040-2) EFTA01710221 ERs Studen