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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Part 1, Chapter 12:  Manual Appendix X

Immunization Form


SUGGESTED IMMUNIZATION FORM

Name:__________________________________ Sex:_____ Birthdate:________

VACCINE VACCINE TYPE DATE GIVEN MO/DAY/YR VACCINE LOT# DOCTOR OR CLINIC DATE DOSE DUE
                 

TN 01-1 (4/17/91) Indian Health Manual


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