I give consent for the following vaccine(s) to be given, in my absence, to my child(ren) by Dr. Deborah Ungerleider or her office nurse, in my absence, for my child (children),
Parent/Legal Guardian Name & Signature
City, State and Zip Code
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Deborah L. Ungerleider, MD, LLC
44 Godwin Ave Suite 100
Midland Park, NJ 07432
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