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to Medications, Food): Prescription Medications: Date of Last Tetanus Injection/Booster: Child s Medical Care and Insurance Information Physician/Pediatrician: Phone Number: Dentist/Orthodontist: Phone Number: Preferred Medical Facility: Insurance Company: Policy/Group Number: Policy Holder: SIGNATURE OF PARENT/GUARDIAN Signature Date Print Name WITNESS Witness Signature Date Print Name Address Witness Signature Date Print Name Address NOTARY ACKNOWLEDGMENT State of County of On this day of in the year 20 before me, , appeared , who is personally known to me or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he or she executed it..
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