Medical Verification Form For COVID-19 Vaccine

Health Care Provider Information
Medical Conditions
- Cancer
- Chronic Kidney Disease
- COPD (Chronic Obstructive Pulmonary Disease) and
  other high-risk pulmonary disease
- Down Syndrome
- Heart Conditions, such as heart failure, coronary
  artery disease, or cardiomyopathies
- Immunocompromised states
- Obesity (body mass index of 30 kg/m or higher)
- Pregnancy
- Sickle cell disease
- Type 2 Diabetes Mellitus
Note: This list does not contain every condition that might increase one’s risk for developing severe illness from COVID-19, such as those for which evidence may be limited (e.g., rare conditions or combinations of conditions). The health care provider is allowed to vaccinate any patient assessed to have significant risk for severe illness due to comorbidities, even if not listed here.
I, the Health Care Provider, believe that
Since the patient described above has two or more medical conditions, it may put the patient at significantly increased risk for severe COVID-19 infection or death.Since the patient described above is a family caregiver of a child under 16 who has two or more medical conditions, it may put the child at significantly increased risk for severe COVID-19 infection or death.Other
Health Care Provider
First NameLast Name
License #
or NPI
Provider
Provider FacilityPractice Name
Address
CityState / Province
Phone Number
Please enter a valid phone number.
Date
MonthDayYear
Date
Signature
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Should be Empty: