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Get MD 896 2011-2023

Rgency or epidemic of disease. Signed: _____________________________________________________________________ DHMH Form 896 Rev. 2/11 Date: _______________________ Center for Immunization www.EDCP.org (Immunization) How To Use This Form The medical provider that gave the vaccinations may record the dates directly on this form (check marks are not acceptable) and certify them by signing the signature section. Combination vaccines should be listed individually, per each component of the vaccine.

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