Immunization Form - Medical Exemption From Immunization printable pdf download

Immunization Form - Medical Exemption From Immunization

Immunization Form

This form is to be completed by all students born on or after January 1, 1957.

PERSONAL INFORMATION

(To be completed by the student)

Name

First

Last

Middle (complete)

Date of Birth

Social Security Number

Touro I.D. (if any)

Prog/Ext

MAILING ADDRESS

Number and Street

Apartment #

City

State

Zip/Postal Code

Day Phone (

)

Evening Phone (

)

Check at least one of the statements below.

Vaccination Record below is complete for each disease. I have no acceptable alternate record or exemptions to submit.

Alternate records are attached for each disease.

Medical Exemption on reverse is complete for each vaccination for which I claim medical examination.

Signature

Date

VACCINATION RECORD

(To be completed by the health practitioner)

Measles

Rubella

Mumps

or Combined MMR

Vaccination Date

Dose 1

(Two doses required for

Does 2

Measles or MMR)

Disease history

(Date of Onset)

Serology Date and Results

(Indicate + or –)

Include copy of lab report

Scheduled Date for Dose 2

Important Note About Revaccination:

Measles–If administered prior to 1968 and not specified as “live” and/or if student was less than 12 months of age for first dose and/

or less than 15 months of age for second dose, vaccination must be repeated. Indicate date for follow-up. Mumps and Rubella–If

vaccination was given prior to 1969 and/or if patient was less than 12 months of age, vaccination must be repeated.

I certify that the above information is correct. (Must be signed by health practitioner)

Signature

Name /Title

Date

(

)

Clinic

Address

Phone

Immunization Form - Medical Exemption From Immunization

Related Articles

Related forms

Related Categories