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Get and Sign the Giver Split Page Notes 13 16 Form

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Person named below to get the vaccine. I freely and voluntarily give my signed permission for the vaccines. Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See for more information on Privacy...
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