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Get KS Certificate Of Immunization (KCI) - Form B 2019-2024

Ng vaccine(s): ( ) DTaP/DT ( ) Tdap/Td ( ) Pertussis Only ( ) Polio ( ) MMR ( ) Hib ( ) Rotavirus ( ) Hepatitis A ( ) Hepatitis B ( ) Pneumococcal Conjugate ( ) Meningococcal Conjugate ( ) Varicella ( ) Human Papillomavirus ( ) Other: I certify the physical condition of this child to be such that the inoculation(s) specified on this form would seriously endanger the life or health of this child. Signature: Date: PLEASE PRINT Name: Street Address: City: State: Zip Code: Telephone: Medical .

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