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FLORIDA 'CERTIFICATE OF IMMUNIZATION (HRS 680 - PART A) . (Florida Stlutes 232.032)
FOR CHILDREN WHO HAVE COMPLETED ALL REQUIRED IMMUNIZATIONS FOR SCHOOL ATTENDANCE
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 PARENT LA GUARDIAN
IF THE FOURTH PRIMARY DOSE OF DT
DT (PEDIATRIC) VACCINE IS ACCEPTA
Td (ADULT) VACCINE (A SERIES OF 3
POLIO (TOM) - 1 DOSES 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 opidEjle
••• ,
•
;AFAR Fs SINGLE - 1 DOSE AT 12 MONTHS rOR
MUMPS SINGLE - 1 DOSE AT 12 MONTHS OF ABE OR
ri7P•A v.. Lsi ,41.••••
RUBELLA SINGLE - I DOSE AT 12 MOITHS OF AGE OR OLDER
THE CHILDREN'S IAD DA
galistrh ifeLODING 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 •
MO DA YR
MO DA YR
ROYALPALM Uth 33411
PHONE
MOW OR WPM NAME (PLEASE PRINT) „„14)All CR AUTHORIZED SIONATORE ,YR
.ao 9 a DATE
• • - „ft,.
CONFIDENTIAL A4n La ••... a Mall. di.' NA. 31._• 4.•
MM08-V ZALIS-000008
3501.225-004
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