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    Immunization Records

    Birthdate
    Birthdate
    Required Vaccines
    MMR - 2 doses OR positive titers Minimum of 4 weeks between doses 1st dose given after 1st birthday
    MMR Dates #1
    MMR Dates #1
    MMR Dates #2
    MMR Dates #2
    or Postiive Titer Date (MMR)
    or Postiive Titer Date (MMR)
    Option of combined MMR OR Individual vaccines
    Measles #1
    Measles #1
    Measles #2
    Measles #2
    or Positive Titer Date (Measles)
    or Positive Titer Date (Measles)
    Mumps #1
    Mumps #1
    Mumps #2
    Mumps #2
    or Postiive Titer Date (Mumps)
    or Postiive Titer Date (Mumps)
    Rubella #1
    Rubella #1
    Rubella #2
    Rubella #2
    or Postiive Titer Date (Rubella)
    or Postiive Titer Date (Rubella)
    Tdap booster within last 10 years
    Tdap
    Tdap
    Meningococcal / MCV4 (required) Meningitis B. (recommended) - One dose given at age 16 or older
    Meningococcal (dose at age 16 or older) MCV4 (required) Meningitis B. (recommended)
    Meningococcal (dose at age 16 or older) MCV4 (required) Meningitis B. (recommended)
    2 doses varicella, OR history of disease.
    Minimum of 12 weeks apart if vaccinated between 1 and 12 years of age and at least 4 weeks apart if vaccinated at age 13 years or older.
    Varicella (Chickenpox) #1
    Varicella (Chickenpox) #1
    Varicella (Chickenpox) #2
    Varicella (Chickenpox) #2
    OR History of Disease Date:
    OR History of Disease Date:
    Hepatitis B:  Three doses usually scheduled at 0, 1 and 4 months Minimum 4 weeks between doses 1 and 2 Minimum 3 months between doses 2 and 3 Minimum 4 months between dose 1 and 3
    Hepatitis B #1
    Hepatitis B #1
    Hepatitis B #2
    Hepatitis B #2
    Hepatitis B #3
    Hepatitis B #3
    COVID Vaccine Records
    COVID 19 #1 - Pfizer-BioNTech / Moderna / or Johnson & Johnson
    COVID 19 #1 - Pfizer-BioNTech / Moderna / or Johnson & Johnson
    COVID 19 #2 - Pfizer-BioNTech / Moderna / or Johnson & Johnson
    COVID 19 #2 - Pfizer-BioNTech / Moderna / or Johnson & Johnson
    COVID 19 Booster
    COVID 19 Booster

    Recommended Vaccines
    Hepatitis A: Recommended if planning to travel 6-12 months between doses
    Hepatitis A #1
    Hepatitis A #1
    Hepatitis A #2
    Hepatitis A #2
    HPV - Health Care Maintenance - Human papillomavirus
    HPV #1
    HPV #1
    HPV #2
    HPV #2
    HPV #3
    HPV #3
    Polio - Primary Series (Most recent)
    Polio Oral
    Polio Oral
    Polio Injectable
    Polio Injectable