COVID-19 Determination of Extreme Vulnerability
Physician Name:__________________________________________________________________________________________
Last/Surname First Middle
Physician License Number: Physician Telephone Number: _______________________ ____________________
Physician Practice Address: ______________________________________________________________________
Physician Email Address:__________________________________
Patient Name: __________________________________________________________________________________________
Last/Surname First Middle
Patient Date of Birth: ________________________________
Patient Address: ________________________________________________________________________
City: _________________________ State: ______________ ZIP Code: _______________________
Patient Telephone Number: ________________________________________
CERTIFICATION OF PATIENT’S EXTREME VULNERABILITY TO COVID-19
I hereby certify that I have a physician-patient relationship with the patient named above and
that I have determined that the patient is extremely vulnerable to COVID-19 for the purposes of
receiving a COVID-19 vaccination in the state of Florida.
I attest that I am the physician listed above and the statements in this determination are true
and complete.
Physician’s Signature: ___________________________________________________ Date:
MM/DD/YYYY
___________
DH8014-DCHP-03/2021, 64DER21-3 Page 1 of 1
