Hepatitis A Immunization Medical Exemption Form printable pdf download

Hepatitis A Immunization Medical Exemption Form

HEPATITIS A IMMUNIZATION

MEDICAL EXEMPTION FORM

This is to certify that ______________________________ should be

exempted from receiving Hepatitis A immunization because:

____ S/he has documented laboratory evidence of immunity to

Hepatitis A (Attach laboratory slip to this form)

____ She is pregnant, with expected delivery date of _________________

____ In my medical judgment, Hepatitis A immunization would endanger

his/her health or life

____ S/he has been vaccinated against hepatitis A as follows:

First vaccination date

______________________

Date of booster shot

______________________

____ Other (Specify)

_______________________________________________________

Health care provider name (Print or type) _______________________________

Health care provider signature ________________________________

Physician registation number, if applicable _____________________

Date ___________________

Return form to:

Saint Louis County DOH/CDC

111 South Meramec

Clayton, MO 63105

Hepatitis A Immunization Medical Exemption Form