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Influenza Vaccination Medical Exemption Request Form To be completed by requestors personal health care providerPatient Name: ___Date of Birth: ___Longstreet Clinic is committed to protecting our

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How to fill out influenza vaccination medical exemption

01

Consult with your healthcare provider to determine if you are eligible for a medical exemption for the influenza vaccination.

02

Obtain a medical exemption form from your healthcare provider's office or from the appropriate health department.

03

Fill out the form completely and accurately, providing any relevant medical information or documentation to support your exemption request.

04

Submit the completed form to your employer, school, or other relevant institution as needed.

Who needs influenza vaccination medical exemption?

01

Individuals who have a medical condition that contraindicates receiving the influenza vaccination may need a medical exemption.

02

This includes individuals with severe allergies to vaccine components, a history of Guillain-Barré Syndrome, or other medical reasons as determined by a healthcare provider.

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What is influenza vaccination medical exemption?

Influenza vaccination medical exemption is a medical certificate signed by a healthcare provider stating that an individual should be exempt from receiving the influenza vaccine due to medical reasons.

Who is required to file influenza vaccination medical exemption?

Individuals who are unable to receive the influenza vaccine due to medical reasons are required to file influenza vaccination medical exemption.

How to fill out influenza vaccination medical exemption?

To fill out influenza vaccination medical exemption, an individual must consult with a healthcare provider who can assess their medical condition and provide a medical certificate stating the exemption.

What is the purpose of influenza vaccination medical exemption?

The purpose of influenza vaccination medical exemption is to protect individuals who are unable to receive the influenza vaccine due to medical reasons from being penalized for non-compliance with vaccination requirements.

What information must be reported on influenza vaccination medical exemption?

Influenza vaccination medical exemption must include the individual's name, date of birth, medical condition preventing vaccination, healthcare provider's name and signature, and date of exemption.

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