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  1. COVID19 Consent Form

    New York State Department of Health Bureau of Immunization COVID-19 Immunization Screening and Consent Form*: Children and Adolescents Ages 5 – 12 years old Recipient Name (please print) Preferred Name DOB Current Gender...

  2. covid19-immunization-screening-and-consent-form-spanish

    Spanish New York State Department of Health Bureau of Immunization Formulario de detección y consentimiento de vacunación contra el COVID-19 *: para niños y adolescentes entre 5 y 12 años Nombre del beneficiario (escribi...

  3. covid19-immunization-screening-and-consent-form-chinese

    New York State Department of Health Bureau of Immunization COVID-19 免疫篩檢及同意書*:5 - 12 歲兒童和青少年 接種者姓名(請正楷填寫) 首選姓名 出生日期 當前性別認同 代碼: W – 女人/女孩 TW – 變性女人/女孩 M – 男人/男孩 請在下方註明: TM – 變性男人/男孩 NB – 非二元性別 GNC – 非常規性別 Q –不確定/質疑中 NR – ...

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