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PENNSYLVANIA DEPARTMENT OF HEALTH …

H502.320 03/17 Page 1 Name Birthdate Address Parent or Guardian Telephone Please circle present grade: K 1 2 3 4 5 6 7 8 9 10 11 12 Other

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Text of PENNSYLVANIA DEPARTMENT OF HEALTH …

03/17 Page 1 Name Birthdate Address Parent or Guardian Telephone Please circle present grade: K 1 2 3 4 5 6 7 8 9 10 11 12 Other VACCINE Circle appropriate item Enter month, day and year each immunization will be given DOSES Diphtheria,tetanus and acellular pertussis (DTaP, DTP, Td or DT) 1 / / 2 / / 3 / / 4 / / 5 / / Tetanus, diphtheria and acellular pertussis (Tdap) 1 / / 2 / / 3 / / 4 / / 5 / / Polio (OPV or IPV) 1 / / 2 / / 3 / / 4 / / 5 / / Hepatitis B 1 / / 2 / / 3 / / 4 / / 5 / / Measles - mumps - rubella (MMR) 1 / / 2 / / or measles serology Date Titer Varicella 1 / / 2 / / Rubella serology Date Titer Meningococcal (MCV) 1 / / 2 / / Other 1 / / 2 / / Mumps disease diagnosed by a physician: Date Attach EHR of vaccines already given. X_______________________________________ ___________________________________ 3/17 Signature (PLEASE CIRCLE - physician, certified registered nurse practitioner, physician assistant, local health department) PENNSYLVANIA DEPARTMENT OF HEALTH MEDICAL CERTIFICATE

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