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Get Consent Immunization Form 2014-2024

I ask that the vaccine(s) checked below be given to me or to the person named below for whom I am authorized to make this request. I consent to inclusion of this immunization data in the Kansas Immunization Registry for myself or on behalf of the person named below. DT DTaP MMR Tdap PCV13 Td HepA PPV23 HepB Polio/IPV Hib HPV Influenza Rotavirus Meningococcal Varicella Other_ Signature of Patient or Parent/Guardian Date PATIENT INFORMATION Patient’s Last Name: Street Address:.

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