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Get OR DHS 53-05A 2014

E signed prior to a child’s attendance at school, preschool, child care or home day care. This information is being collected on behalf of the Oregon Health Authority, Immunization Program and may be released to the Authority or the local public health department by the school or children’s facility upon request of the Authority. Please list immunizations in the order they were received. Middle Initial Segundo Nombre Birthdate Fecha de Nacimiento Mailing Address Dirección City Ciudad S.

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