Michigan documentsmdhhsGRETCHEN WHITMER DEPARTMENT OF HEALTH AND HUMAN SERVICES 2025

1. Click ‘Get Form’ to open the Michigan Medical Contraindication Form in the editor.
2. Begin by filling in the required fields. Enter the child's name, date of birth, and parent/guardian's name clearly.
3. Provide the home address and telephone number for contact purposes.
4. Specify the preschool program, childcare center, or school name where the child is enrolled.
5. Indicate which immunizations are medically contraindicated by checking the appropriate boxes.
6. In the 'Reason for exemption' section, provide a brief explanation as required.
7. Fill in the date until which the exemption shall continue.
8. Complete physician details including their name, office address, and telephone number.
9. Ensure that the physician signs and dates the form before submission.

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