Eureka College New Student Packet 2013-14 | Page 15

To be completed by a physician or health care professional
Student’s Name: ________________________________________________________________________

Last
First

Middle Initial

Please provide the month, day, and year for every dose administered.

1. Diphtheria, Pertussis and Tetanus

___ /___ /___ ___ /___ /___ ___ /___ /___

2. Tetanus Boosters

___ /___/___

___ /___/___

3. Combined Measles/Mumps/Rubella
___ /___ /___