Fillable Bacterial Meningitis Immunization Medical Exemption Affidavit (University of North Texas Health Science Center)

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Bacterial Meningitis Immunization Medical Exemption Affidavit (University of North Texas Health Science Center)

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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:
University of North Texas Health Science Center Office of the
Registrar, SSC 240
3500 Camp Bowie Blvd.
Fort Worth, TX 76107-2699
Phone (817) 735-2201
Fax (833) 431-1243 /ADA (855) 604-0915
health@unthsc.edu
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Bacterial Meningitis Immunization Medical Exemption Affidavit (University of North Texas Health Science Center)

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Completed 2 February 2021

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