TMANIPAL

ACADEMY HIGHFR EDUCATON

STUDENT IMMUNIZATION RECORD

Proof of immunization or immunity is REQUIRED OF ALL STUDENTS in order to register at the University.
Note that a Registered Medical Practitioner must sign the form OR you must attach an official certificate from the
Health Department. Incomplete forms will be returned.

Name JAYANT GARG Date of Birth 2 10 2.00

Roll Number_ 2204o1|84 Phone number 788836035
Institution MC: 0 D:S Mangalesu
IMMUNIZATION HISTORY: (This section is to be completed and signed by a registered medical practitioner)

HEPATITIS B
Date.1)512/
Date: 1) 2 Date. 2) SSL200 Date: 3) 2200
AND
Hepatitis B Antibody Tite Date: Immune Not Immune. Value:

VARICELLA ICHICKEN POX:

1st immunization Date: 2nd immunization Date

Date of disease (month & year):

21a2el0-OR
-OR

Varicella Titer: Date: Immune Not Immune Value:

MUMPS, MEASLES (RUBEOLA), RUBELLA:

1stimmunization Date: 2S7 2nd immunization Date:25 4. 2006
-OR

Mumps Titer: Date: Immune Not Immune Value:

Measles Titer: Date: Immune Not Immune. Value:

Rubella Titer: Date: Immune Not Immune Value

EDICAL HISTORY

Allergies

Current medications NO
Current medical conditions NAD

Significant past medical history NO

Provider Name (Print)

Medical Council Registration Number PoL NLo 30366

149,3430oS
Signature Date 25.Noy.20Daytime Phone (
Address O CuiL SuaafoN_LAPuRThmA ADuRTHA 1460
NeR STATE GuO APA
Street City/State Pin code

S1.Ennemiolog1st
e Cvil Surgeon.
dhaa.
DECLARATIPN TO BE SIGNED BY THE STUDENT:
Ihereby declare thatthe particulars mentioned in the form are true to the best of my knowledge and belief, and
no material information has been concealed or withheld which has a bearing on selection.

Signature of the Student: 0oet 4aMa Date: 25l|:22