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Get Childhoodadolescent Immunization Administration Record Form

Birth Date: M F Address: City: State: Zip: Parent, Guardian, or vaccine recipient - Please read and initial. Initials Statement 1: I have read or have had explained to me the information contained in the Vaccine Information Statements (VISs) about the following disease(s) and vaccine(s): Diphtheria, Tetanus, Pertussis, Polio, Measles, Mumps, Rubella singly or in combination, Haemophilus Influenzae type b, Hepatitis A, Hepatitis B, Varicel.

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