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Click ‘Get Form’ to open the dhhs 3987 form in the editor.
Begin by filling out the patient information section, including the name, date of birth, and address of both the patient and parent/guardian.
Indicate the school or child care program that the patient is associated with.
Review the list of vaccines and check any applicable contraindications or precautions that apply to the patient. Be sure to document any specific reactions as required.
Complete the section regarding when the exemption ends and provide your name as a physician, ensuring it is printed clearly.
Attach a copy of the most current immunization record before finalizing your submission.
Retain a copy for your records and return the original form to the requesting party.
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