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Get and Sign NEVADA COUNTY PUBLIC HEALTH DEPARTMENT Immunization Record 2021-2022 Form

Get and Sign NEVADA COUNTY PUBLIC HEALTH DEPARTMENT Immunization Record 2021-2022 Form

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Found YES NO FOR INTERNAL USE ONLY If Yes Patient ID Method of Release FAX E-MAIL MAIL PORTAL IN PERSON Photo ID Information State or Country Number Expiration Staff Completing Request Rev 10-21. Name OR Organization Mail E-mail Fax In Person My KS Health Portal Note This is not an option if records are being released to an organization. Phone Number E-Mail Address Fax Number All Immunizations Covid-19 Only Both This authorization will automatically expire one 1 year from the date signed. I...
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