EFTA01248869.pdf

F-7-5:5•73,717.1-.3sitr::•-e,r,•47,...4 • t„,t1A rverneate4 FLORIDA 'CERTIFICATE OF IMMUNIZATION (HRS 680 - PART A) . (Florida Stlutes 232.032) FOR CHILDREN WHO HAVE COMPLETED ALL REQUIRED IMMUNIZATIONS FOR SCHOOL ATTENDANCE PARENT LA GUARDIAN DOCTOR: PART A OF THIS FARR IS USED CRT IF 111E NILO HAS RECEIVED ALL REQUIRED IMMONZATIONS LISTED BROX IF NOT. SEE MERE SIDE. OTP - 5 DOSES REWIRED IF THE FOURTH PRIMARY DOSE OF DT DT (PEDIATRIC) VACCINE IS ACCEPTA Td (ADULT) VACCINE (A SERIES OF 3 POLIO (TOM) - 1DOSES REQUIRED IF THE THRD PRMARY DOSE OF TOW IS ANDIISTcRE13•1)(41111nOSPOIMpi .,..... rTpa 1A.C4111- OSEJS,NO1b, f".‘ POW VACCINE IS OMITTED FROM THE REOCIIFIED IMNIAR110114:044311f) 113L S,. /PlEd3Efic _ MEASLES. MUNK AND SUMO - I DOSE MHO • ..,:p.4 ,..aessit.r.,*;•4 ; ; rt<I MMR COMBINED - 1 DOSE AT 12 MONTHS opidEjl e • ••• , • ;AFAR Fs SINGLE - 1 DOSE AT 12 MONTHS rOR MO DA YR MUMPS SINGLE - 1 DOSE AT 12 MONTHS OF ABE OR MO DA YR ri7P•A v.. Lsi ,41.•••• RUBELLA SINGLE - I DOSE AT 12 MOITHS OF AGE OR OLDER THE CHILDREN'S IAD DA YR galistrh i feLODING BIRTHDATE MUST BE ENTERED. AND THE CERTIFICATE SIGNED BELOW BY A PHYSICIAN OR AUTHORIZED PERSON AND pATTAbliyaftc63. OR THE CHILD TO ATTEND SCHOOL STANLEY DOBER, M.D. I HAVE RE AVAILABLE AND TO THE BEST OF MY KNOWLEDGE THE ABOVE NAMED GILD HAS BEEN ADEQUATELY IMMUNIZED AGAINST DIPHTH VOUO, MEASLES, MUMPS, AND RUBELLA AS REQUIRED BY FLORIDA LAN FOR SCHOOL ATTENDANCE SUITE 201 ROYALPALM Uth 33411 PHONE , .ao 9 a MOW OR WPM NAME (PLEASE PRINT) „„14)All CR AUTHORIZED SIONATORE DATE • •- „ft,. A4n La ••... a Mall. di.' NA. 31._• 4.• MM08-V ZALIS-000008 3501.225-004 CONFIDENTIAL Page 1 of 1 EFTA_00075149 EFTA01248869