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Get Vaccine Information Statement 2012-2024

________________________ *Date of Birth: ______________ *Phone# _________________ *Address: _______________________________ *City: ___________________________ *State: _____ *Zip:_________ *Gender: M or F *Primary Doctor: _________________________________ *Dr. Phone: ____________________ *Which vaccine(s) would you like to receive today? _______________________________________________________ *Medical Conditions: ___________________________________________ *Enter Weight if less than 110 lbs: ____.

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  5. Put the date.
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