Epstein Secrets

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nical reasoning or evidence for exemption: DOE Code 3 I cent& that the physical condition of this child is such that immunizations) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: DII 450, Pd2000, obsoletes whet

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inical reasoning or evidence for exemption: DOE Code 3 I cestift that the physical condition of this child Lt nth that immenitatiomNat indicated in Pan C above is medically caltraindicated. Physician or Clinic Name: (flint or stamp) Address: D44 610, 1196. dada= la (4Omo (SIM Maher 574.11O:MX1106)

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cal reasoning or evidence for exemption: DOE Code 3 I certify that he physical condition of this child is such that immunization(s) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Address. Physician Signature. DN 680, &NS repbces earlier ed

nder O i - American Indian/Alaskan Native O B - Black Non-Hispanic O H - Hispanic O W - Whke, Non-His

nical reasoning or evidence for exemption. DOE Code 3 1 cent that the physical condition of this child is such that immunization(s) as indicated in Pan C above is medically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: DH 680, 8/2000, obsoktm tallitt