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Get Form Instructions Pdf - 69 Kb - Cdc

Ty to place identification information of the facility as indicated or required by the facility. Patient identifiers Required. Blank space for facility to place patient identification label or stamp as indicated. Minimum information required includes the alphanumeric patient ID (i.e., the patient identifier assigned by the hospital and may consist of any combination of numbers and/or letters), gender, and date of birth. DO NOT VACCINATE Optional. Check one of the choices. Vaccine offered Require.

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