Certificate Of Immunization Form Page 2
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1
2Certificate of Immunization
(page 2 of 5)
STRONGLY RECOMMENDED IMMUNIZATIONS
A. Hepatitis B immunization series
Dose 1. ___/___/___
Dose 2. ___/___/___ Dose 3. ___/___/___
mo. day
yr.
mo. day
yr.
mo. day
yr.
B. Meningococcal vaccine ___/___/___
mo. day
yr.
C. History of Chickenpox OR chickenpox vaccine
1. Chickenpox: ___/___/___
mo. day
yr.
OR
1. Chickenpox vaccination:
___/___/___
Dose 1.___/___/___
mo. day
yr.
mo. day
yr.
Human Papilloma Virus (HPV)
Dose 1. ___/___/___
Dose 2. ___/___/___ Dose 3. ___/___/___
mo. day
yr.
mo. day
yr.
mo. day
yr.
OTHER IMMUNIZATIONS
A. ___________________________ Dose 1. ___/___/___
Dose 2. ___/___/___ Dose 3. ___/___/___
mo. day
yr.
mo. day
yr.
mo. day
yr.
B. ___________________________ Dose 1. ___/___/___
Dose 2. ___/___/___ Dose 3. ___/___/___
mo. day
yr.
mo. day
yr.
mo. day
yr.
C. ___________________________ Dose 1. ___/___/___
Dose 2. ___/___/___ Dose 3. ___/___/___
mo. day
yr.
mo. day
yr.
mo. day
yr.
___________________________________________________________________________
____________________________
Medical Provider Signature
Date
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