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Get Health Cqrtificate Form

L FORM Name: School: Date of Birth: Gender: q M q F Grade: I give permission for the exam to be done in school: Parent Signature: Date: IMMUNIZATIONS / HEALTH HISTORY q Immunization record attached..................................... Sickle Cell Screen: q Positive q No immunizations given today.......................................................... PPD: q Positive q Immunizations given since last Health Appraisal:............. Elevated Lead: q Yes Dental Referral: q Yes.

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