Vaccine Exemption Form

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Vaccine Medical Exemption

Patient Name

First Name

Last Name

Date of Birth

Parent/Guardian Name

First Name

Last Name

Relationship

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

General Contraindications (Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component )

Hepatitis B Diptheria, tetnus, pertussis Inactivated poliovirus Measles, mumps, rubella Varicella Meningococcal, conjugate Meningococcal, polysaccharide

Which vaccine or vaccine component caused the reaction?

Type of Clinical Reaction

Date of Clinical Reaction

Vaccine Specific Contraindications (Vaccine should NOT be given.)

DTaP or Tdap

Encephalopathy (e.g., coma, decreased level of consciousness, prolonged seizures) not attributable to another identifiable cause within seven days of administration of previous dose of DTP or DTaP

MMR

Encephalopath (e.g., coma, decreased level of consciousness, prolonged seizures) not attributable to another identifiable cause within seven days of administration of previous dose of DTP or DTaP Pregnancy Known severe immunodeficiency (e.g., hematologic and solid tumors; receiving chemotherapy; congenital immunodeficiency; long term immunosuppressive therapy; or patients with HIE infection who are severely immunocompromised)

Estimated Date of Confinement (EDC)

Varicella

Pregnancy Substantial suppression of cellular immunity

Estimated Date of Confinement (EDC)

Other Medical Contraindication

Please indicate the duration of the medical exemption, and if and when vaccine can be safely administered.

Medical exemption is permanent, and will apply for (1) year from today's date. Medical exemption is temporary (<1 year), and resolution is anticipated Medical exemption is pregnancy

Estimated Date of Confinement (EDC)

Physician Name

First Name

Last Name

Physician License Number

Office Address

Address Line 1

Address Line 2

City

State

ZIP Code

Today's Date

Physician Signature

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Vaccine Medical Exemption

Vaccine Specific Contraindications (Vaccine should NOT be given.)

Vaccine Specific Precautions (Vaccine may be given or held depending on clinical situation.)