Immunization Checklist

NAME: ___________________________________________ DOB: ______/______/_______ (DD/MM/YYYY) 

Vaccine Year vaccine(s) last received* Notes

Diphtheria-tetanus (dT)

Pertussis

Measles (Rubeola)

Mumps

Rubella

Hepatitis B

Varicella

Influenza

NOTE: Provincial/territorial guidelines may vary or change.

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