Fillable Printable Medical Exemption Form - Arizona

Medical Exemption Form - Arizona

ADHS Immunization Program Office http://www.azdhs.gov/phs/immunization/ July 1, 2013

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____________________

Parent/Guardian Section:

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.

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.

(www.azdhs.gov/phs/immun/index.htm).

Parent/Guardian Signature_____________________________________________________Date____________________________

Arizona Revised Statutes 15-873, http://www.azleg.state.az.us/ars/15/00873.htm, and Arizona Administrative Code, R9-5-305, http://www.azsos.gov/public_services/Title_09/9-05.htm,

and R9-6-706, http://www.azsos.gov/public_services/Title_09/9-06.htm

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

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 per manent exemption or a temporary exemption

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