ical reasoning or evidence for examptioo: DoE Ccdp 3 I her*, that the pluaiced condition of this child Is such that immurazation(s) as indicated in Pan C &bowie medically contraindicated. Pieta or Clinic Name: "tint or stamp) • Address: VIM II 54. 0.4,1/4“.1:te °Lied (Swat Oat: 31000)0004) Physician Sig