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Meningitis Vaccination Fax Cover Sheet

Texas A&M Health Science Center
Fax: 979.436.0099
First:_______________ MI_____ Last:_______________
UIN: __________________________________________
Date of Immunization ____________________________
Number of Pages __________
Please attach at least one of the following:
  1. A document bearing the signature or stamp of the physician or his/her designee, or public health personnel (date included)
  2. An official immunization record generated from state or local health authority (date included)
  3. An official record received from school officials, including a record from another state (date included)
  4. An affidavit declining vaccination