CHILDS NAME DOCTOR: PART A OF THIS FORM IS USED ONLY IF THE CHILD HAS RECEIVED ALL REQUIRED IMMUNIZATIONS LISTED BELOW. IF NOT. SEE REVERSE SIDE. (Florida Stalute 232.0:2) DATE OF BIRTH DIP — 5 DOSES REQUIRED IF THE FOURTH PRIMARY DOSE OF DT- DT (PEDIATRIC) VACCINE IS ACCEPTABLE IF PERIU Td (ADULT) VACCINE IA SERIE