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Medical Contraindication Form - Michigan - michigan 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the child's full name in the designated field, ensuring accuracy for official records.
- Next, input the child's birth date in the format of Month/Day/Year to confirm their age.
- Specify the preschool program, childcare center, or school name where the child is enrolled.
- Indicate which immunizations are medically contraindicated by checking the appropriate boxes next to each vaccine listed.
- Provide a detailed reason for exemption in the space provided, ensuring clarity for health officials.
- Fill in the expiration date of the exemption using Month/Day/Year format.
- Print and complete the physician's name and address, along with their telephone number.
- Ensure that the physician signs and dates the form before submission.
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