Vaccine exemption letter pdf ny 2026

1. Click ‘Get Form’ to open the vaccine exemption letter in the editor.
2. Begin by filling in the patient's name, date of birth, and address in the designated fields. This information is crucial for identifying the individual requesting the exemption.
3. Indicate the specific vaccine(s) for which you are seeking an exemption by checking the appropriate boxes. Options include Hib, MMR, Polio, Varicella, Hep B, PCV, and DTaP.
4. In the contraindication/precaution section, provide detailed information regarding any medical reasons that justify the exemption. This should be completed thoughtfully to ensure clarity.
5. If applicable, specify the date when the exemption ends. This helps institutions understand the duration of the exemption.
6. Complete the medical provider's information section with their name, NYS Medical License number, address, telephone number, signature, and date. This validates your request.
7. Once all fields are filled out accurately, save your document. Retain a copy for your records and return the original to the requesting facility or person.

Start using our platform today to easily complete your vaccine exemption letter for free!