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COVI

D-19Vac
cinat
ionRec
ordCar
d
Pl
ea ekeepthi
srec
ordcard,
whichincludesmedi
cali
nfor
mat
ion
aboutthevacci
nesyouhavere
ceived.
Porfavor
,guar
dee s
tata
rtej
aderegisto,quei
ncl
uyei
nfor
macion
me dic
aobrelasva
cunaqueharecibido.

L
ast
Name F
ir
stNa
me MI

Da
teof
bir
th P
ati
ent
numbe
r(me
dic
alr
eco
rdo
rII
Sre
cor
dnumbe
r)

1s
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COVI
D-19 mm dd yy
2r
d
Dos
e . .
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COVID-19 mm dd yy
_
___
/__
__/
____
Ot
her
mm dd y y
_
___
/__
__/
____
Ot
her
mm dd y y

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