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Only a medical provider local health department official school official or child care provider may sign Record of Immunization section of this form. This form may not be altered changed or modified in any way. This exemption does not apply during an emergency or epidemic of disease. DHMH Form 896 Rev. 2/14 Center for Immunization www. dhmh. maryland. gov How To Use This Form The medical provider that gave the vaccinations may record the dates us.

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