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Adobe PDF Adobe PDF document  Statement of Medical Exemption – Immunization of School Pupils ActThe file you are about to download will ONLY work properly if opened with an Adobe Reader 10 or later client. Please do not open this file in a browser.Fill, Print & Save132.0 kb

Form Classification
Classification / Identification:
 Form Number:014-4895-64EEdition date: 2013/08 
 Title:Statement of Medical Exemption – Immunization of School Pupils Act
 Branch/ABC:Public Health  
 Program:Public Health  
 Purpose of Form:A physician or nurse practitioner must complete a Statement of Medical Exemption for children who require a medical exemption from vaccine requirements under the Immunization of School Pupils Act.  

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