Student Flu Vaccine Consent Form - Delaware General Health District Page 2

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STOP — AREA BELOW FOR OFFICE USE ONLY
RD /IM
LD/IM
GSK
SP
LOT #:______________________________________
EXP: 6/30/18 EXP:___________________________
VIS DATE:_______08/07/2015_______________
RN: ________________________
Date Given: __________________
Private
VFC
F:\PH\2017\Schools\School Consents\2018\school flu consent fall 2017 2018.pub
revised 7/2017

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