Physician Health Statement Form printable pdf download

Physician Health Statement Form

Health Statement

Physician Form

Name of Child __________________________________________

Date of Birth ________________________

I have examined the above child within the past year and find that he/she is able to take part in the preschool program.

Health Care Professional Name ____________________________________________________________________

Address _________________________________ City ____________________ State ________ Zip _____________

Signature of Physician___________________________________________ Date _________________________

Physician Immunization Record

**Please provide an immunization record for the child listed above. The record

should be signed or stamped by the physician.

Varicella (chickenpox) vaccine is not required if the student has had the chickenpox disease. If the child listed above has

had chickenpox, please complete the statement: ______________ has had varicella (chickenpox) on or about (date)

_________________________and does not need varicella vaccine.

Physician/Parent Signature _________________________________ Date ______________________________________

Immunization Exemption

(This is filled out by the parent only if shots were/are not being given.)

**A notarized state affidavit form must also be completed**

Immunization Exemption: (Parent should complete ONLY if applicable)

I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official

notarized affidavit form developed and issued by the Department of State Health Services. I understand this affidavit is valid for 2 years.

Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of;

I have attached a signed and dated affidavit stating this.

Parent Signature ____________________________________________________________ Date ___________________________________________________

Physician Health Statement Form