ically contraindicated. Physician or Clinic Name: (Print or stamp) Physician Signature: Address: DH 610, 11 /96. absoletet miler oditiccs (Stodc Numb": 5740000068%5) Date: EFTA01710450 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032, s. 10D-3.088, F.A.C. and s.