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Get Vis Date Tetanus 2007-2024

__________________________________ Address _______________________________________________ City __________________State _______ Zip _____________ ( ) Phone _______________________________________ I have been advised my child or ward (named above) should receive the following vaccines, but I am declining to have my child immunized. Declined (Check all that apply) Hepatitis B Vaccine Measles, Mumps, Rubella Vaccine (MMR) Diphtheria Tetanus Vaccine (DT or Td) Influenza (flu) Vaccine Diphth.

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