This government document is issued by Department of Public Health, Georgia Immunization Registry for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://dph.georgia.gov/document/document/ga-wic-medical-data-and-breastfeeding-referral-form42222revised3232023pdf/download&sa=U&ved=2ahUKEwiI86eysvKKAxVFTqQEHd7GAvo4KBAWegQIBBAB&usg=AOvVaw38_1cp8J_XvdMlXl3Z-vNl