WIthekij Speckneefheda Date collectie 09/14/2018 1255 Letal Date reufred: 09115/2018 Date intered: 09/15/2018 Date raportett 09/18/2018 0610 ET Physidan Details Orderlag: W MERRELL Referring: lt MERREU. tut 1023153509 General Comalente & Additional Information Total Vobma: Not Prondod Ordered

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its and second dove of measles marinas documented on the mane side tithes form (bored arrae). Physklan or Clinic Name: (Print or stamp) Address: Physidan or Authorized Signature: Date Temporary Medical Exemption PART B (For preschool children, children in day care and school children who are incomp

d on the reverse side of this fonn (bared Physician or Clinic Name: (Print or stamp) Address: THE PEDIATRIC CENTER, P WELLINGTON, FLORIDA 33414 Physidan or Signature: Date: a Ss Temporary Medical Exemption PART B (For preschool children, children in day care and school children who are incomplete