Physician’s Statement and Vaccination Record

  • Physician’s Statement and Vaccination Record

    1. Please have your physician fill out this form and submit a copy of your child’s vaccination record. Exclusions from immunization records are allowable for medical reasons only. The child must present a statement signed by the child's physician (M.D. or D.O.), duly registered and licensed to practice medicine in the United States who has examined the child, in which it is stated that, in the physician's opinion, the vaccine required is medically contraindicated or poses a significant risk to the health and well-being of the child or any member of the child's household. Unless it is written in the statement that a lifelong condition exists, the exemption statement is valid for only one year from the date signed by the physician.


  • Date Format: MM slash DD slash YYYY
  • Drop files here or

    May be faxed to: 210-226-2103
    Attention School