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DOE Code 2 Permanent Medical Exemption Part C-Permanent Part C For medically contraindicated immunizations list each vaccine and state valid clinical reasoning or evidence for exemption. DOE Code 3 I certify the physical condition of this child is such that immunizations as indicated in Part C above are medically contraindicated. Physician or Clinic Name DH 680 4/09 Stock Number 5740-000-0680-6 Authorized Signature Issued By Date.

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