Epstein Secrets

Clinic Name: Expiration Date: (Print or sump) (15 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 - -

e either physician documented or parental recall (fork' i year) for school attendance as documented on the reverse side of this form. Physician or Clinic Na Physician or (Print or stamp) Authorized Signatu Add Date: Df~ 1)-3 Certificate of Immunization Supplement for 7th Grade Requirement PART A-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

ve with the 1997/98 school year: tetanus-diphtheria booster, hepatitis B vaccine series, and second dose of measles vaccine as docurn. Physician or Clinic Na Physician or (Print or stamp) horized Signatur Addr• Date: --1 1 St (C)--' . Temporary Medical Exemption PART B (For children in child care

Clinic Name: Expiration Date: (Print or sump) (15 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 - -

e either physician documented or parental recall (fork' i year) for school attendance as documented on the reverse side of this form. Physician or Clinic Na Physician or (Print or stamp) Authorized Signatu Add Date: Df~ 1)-3 Certificate of Immunization Supplement for 7th Grade Requirement PART A-2