Parent/guardian Acknowledgement & Agreement Form Vaccination Medical Exemption (Vme) printable pdf download

Parent/guardian Acknowledgement & Agreement Form Vaccination Medical Exemption (Vme)

Dr. William S. Clark, DO

1634 4

St.

Escalon, CA 95320

Parent/Guardian Acknowledgement & Agreement Form

Vaccination Medical Exemption (VME)

Patient (Full) Name: __________________________________________________ DOB ____________

What is a Vaccination Medical Exemption?

A medical exemption is determined state-by-state by the laws specific to that state. An exemption is a matter of

medical opinion. In California:

SB277 120370. (a) If the parent or guardian files with the governing authority a written statement by a licensed

physician to the effect that the physical condition of the child is such, or medical circumstances relating to the child

are such, that immunization (vaccination – my edit) is not considered safe…that child shall be exempt from the

requirements of Chapter 1 (commencing with Section 120325, but excluding Section 120380) and Sections 120400,

120405, 120410, and 120415 to the extent indicated by the physician's statement.

A medical exemption does not prohibit a child from being vaccinated. It does not take away the rights of any

parent, nor stop any parent, from getting another opinion on the safety of vaccines for their child.

A medical exemption does allow a child to attend school if they are not vaccinated or not completely vaccinated.

The child may be excluded from attending school for prolonged periods during outbreaks or exposure to disease for

which vaccination has not been completed.

Acknowledgement & Agreement:

By your signatures below, you agree that your child has a physical condition and/or medical circumstances

indicating that vaccination of your child is not considered safe.

It is required that both parent(s)/guardian(s) sign off on this acknowledgement. This form must be signed in the

presence of our staff during your appointment. Please do not sign the form prior to your appointment.

Parent: Relationship ______________

Print Your Name

Signature

Date

Parent: Relationship ______________

Print Your Name

Signature

Date

Witness:

Print Your Name

Signature

Date

Escalon Physical Medicine –

– (209) 838-3434

Parent/guardian Acknowledgement & Agreement Form Vaccination Medical Exemption (Vme)