Fillable Medical Exemption Form printable pdf download

Arizona law requires that schools, preschools and childcare facilities obtain this form, completed by a physician or

registered nurse practitioner, in order for a child to be exempted from immunization requirements for medical reasons.

Medical Exemption Form

This is the official ADHS-provided form used by physicians and registered nurse practitioners to document that 1) due to the child’s

health or medical condition, the child may be adversely affected on a temporary or permanent basis by one or more of the required

vaccine doses; 2) a child has laboratory evidence of immunity to one or more specific vaccine-preventable diseases and lab results are

attached; or 3) the child has a history of Varicella (chicken pox) disease.

Child’s Name _________________________________________________________________ Date of Birth____________________

To be completed by a physician or registered nurse practitioner to exempt a child from childcare or school immunization requirements.

Printed Name of Physician or Nurse ________________________________________________________________________

Signature of Physician or Nurse ________________________________________________________Date________________

Please list each vaccine included in the exemption and the reason for the exemption:

______________________________________________________________________________________________

Please indicate whether this is a permanent exemption

or a temporary exemption

If the exemption is temporary, please list the date the exemption ends ______________________________________________

Parent/Guardian Section:

1. I am aware that in the event the state or county health department declares an outbreak of a vaccine-preventable disease for

which I cannot provide proof of immunity for my child, he or she may not be allowed to attend childcare and/or school until the

risk period ends, which may be up to 3 weeks or longer.

2. I am aware that additional information about vaccine preventable diseases, vaccines, and reduced or no cost vaccination

services is available from my local county health department and Arizona Department of Health Services.

( ).

Parent/Guardian Signature_____________________________________________________Date____________________________

Arizona Revised Statutes 15-873, , and Arizona Administrative Code, R9-5-305, ,

and R9-6-706,

describe the requirements for medical exemptions in childcare and school settings.

ADHS Immunization Program Office

July 1, 2013

Medical Exemption Form