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Get AR Immunization Consent 2012-2024

ARKANSAS DEPARTMENT OF HEALTH 2014-2015 INFLUENZA SEASON -- IMMUNIZATION CONSENT FORM For ADH use only ADH Clinic Code Date Of Service School Name School Grade If school clinic Person Receiving Vaccine Legal First Name MI Last Date of Birth / 1. Healthy. arkansas. gov posted and available at the clinic site or accompanies this form. Then sign on the first line in the box at right. My signature below indicates I have read understand and agree to s.

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