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 - -

: 354 PASSED READING DSS: 2186 MATH DSS: 2110 FRT PBSD D280 (REV. 7/15/97) EFTA01710068 TEST DATE SAT DE C 05 c1P2ADI COP SA' Program I he College Board S A 550 T I 1 SAT w 500 SAT MC 52 SAT (MY 06 EFTA01710069 Nam STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES CUMULAT

. 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

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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 - -

: 354 PASSED READING DSS: 2186 MATH DSS: 2110 FRT PBSD D280 (REV. 7/15/97) EFTA01727121 TEST DATE SAT DE C 05 c1P2ADI COP SA' Program I he College Board S A 550 T I 1 SAT w 500 SAT MC 52 SAT (MY 06 EFTA01727122 Nam STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES CUMULAT