Bacterial Meningitis Immunization Medical Exemption Affidavit
Notice: THIS FORM IS DUE TEN (10) DAYS PRIOR TO THE FIRST DAY OF CLASS
As the physician of:
Student's Last Name Student's First Name Student's Middle Initial
Student's Date of Birth
UNTHSC Student ID #
The student has not been immunized against Bacterial Meningitis based on the conclusion at this time that it would be injurious to the
student's health.
Comments:
Printed Name of Physician Signature of Physician
Signature Date
Physician's Address: Physician's Phone Number
Return this completed form to:
UNT Health Science Center
Office of the Registrar, SSC 244
3500 Camp Bowie Blvd.
Fort Worth, TX 76107-2644
FAX: (817) 735-0448
Email: Health@unthsc.edu
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