Medical Exception Request Form
Submit your request for a medical exception by providing the required details below. Please ensure all information is accurate and complete.
Full Name of Patient/Requester
*
First Name
Last Name
Relationship to Patient
*
Please Select
Self
Parent/Guardian
Spouse/Partner
Other Family Member
Healthcare Proxy
Other
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Exception Requested
*
Please Select
Medication Exemption
Vaccination Exemption
Procedure Exemption
Mask/Face Covering Exemption
Other
Medical Reason for Exception
*
Requested Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested End Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Attending Provider Name & Practice
*
Upload Supporting Medical Documentation
*
Upload a File
Drag and drop files here
Choose a file
Cancel
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Additional Notes or Comments
Submit Request
Should be Empty: