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FAMILY MEMBER IMMUNIZATION/WAIVER/CONSENT FORM Pediatric Services 4700 Park Glen Road St. Louis Park, MN 55416 Please read the Vaccine Information Statement (IS), complete the following questions,
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How to fill out family member immunizationwaiverconsent form

01
Obtain a copy of the family member immunization waiver consent form.
02
Read the form carefully to understand the information and requirements.
03
Gather all the necessary information, such as the family member's personal details, immunization history, and any medical exemptions or reasons for waiver.
04
Fill out the form accurately and honestly, using black ink or typing if required.
05
Provide all the requested information in the specified sections of the form.
06
If there are any specific instructions or additional documents required, make sure to follow them and attach the necessary paperwork.
07
Double-check the completed form for any errors or missing information.
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Sign and date the form as required.
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Make a copy of the filled-out form for your records.
10
Submit the completed family member immunization waiver consent form to the appropriate authority or organization as instructed.

Who needs family member immunizationwaiverconsent form?

01
Family members who wish to waive immunization requirements for themselves or their dependents may need to fill out the family member immunization waiver consent form.
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Family member immunizationwaiverconsent form is a document that allows individuals to waive immunization requirements for their family members.
Parents or legal guardians of the family members are required to file the immunizationwaiverconsent form.
The form can be filled out by providing the necessary information about the family member, reasons for waiving immunization, and signature of the parent or legal guardian.
The purpose of the form is to provide an option for families to opt out of immunization requirements for their family members based on personal beliefs or medical reasons.
The form must include information about the family member, reasons for waiving immunization, signature of the parent or legal guardian, and any supporting documentation.
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