Public health form
Immunization medical exemption
A medical immunization exemption is how you tell public health that this child (or adult in a covered setting) cannot receive a specific vaccine for a medical reason, or already has documented immunity. In Ontario, school exemptions under the Immunization of School Pupils Act use a Statement of Medical Exemption signed by a physician or nurse practitioner. Conscience and religious exemptions are a different form — you do not sign those as a clinical act.
Medical versus non-medical
Medical exemption is a contraindication or laboratory evidence of immunity. Anaphylaxis to a vaccine component, a specific immunodeficiency, pregnancy for certain live vaccines, or serology showing immunity can belong here. “Parent prefers not to” is not a medical exemption. Direct them to the non-medical process their province actually runs.
Ontario’s medical form is the Statement of Medical Exemption (current ministry form). Other provinces print their own. Use the public-health unit’s current PDF. A letter on letterhead may be accepted only if the unit says so — the named form is safer.
Exemption is vaccine-specific
A true contraindication to MMR is not an exemption from tetanus. Name the antigen. Unvaccinated children can still be excluded during an outbreak. Say that in the visit if it is true in your province. Do not promise they will never be sent home.
Who may sign
In Ontario, a physician or nurse practitioner. Other provinces name the professions on their form. Do not sign a medical exemption for a child you have not assessed. Do not sign a conscience affidavit — that is not your document.
How to complete it
- Child’s identifiers as the school and public health use them.
- Which vaccine or antigen is exempted, and whether this is temporary or permanent.
- The medical reason in the form’s language: contraindication versus immunity.
- If immunity: the lab or disease history the form allows. “Had measles at a cousin’s house” without evidence is weak.
- Your profession, college number, and date.
- Tell the family they must file it with the public health unit, not only with the teacher.
Worked example (fictional)
Medical exemption — documented MMR immunity, paediatrics
Fictional 7-year-old. Do not copy into a real public-health form.
Antigen: measles, mumps, rubella. Reason: laboratory evidence of immunity (IgG positive all three, 2026-06-02) after two documented MMR doses were given abroad without Canadian lot numbers public health would accept. Not a tetanus exemption. Not a conscience statement. Temporary vs permanent: immunity — further MMR not required on current evidence. Family must still file with the public health unit. I am the paediatrician. College number on the Statement of Medical Exemption.
Why public health rejects it
- Signing a medical form for a non-medical reason.
- Exempting “all vaccines” without a reason that covers all of them.
- Missing identifiers or an unsigned form.
- Using last year’s PDF after the ministry revised it.
- Filing only with the school and not the health unit when the statute requires the unit.
Draft the medical exemption from the visit
In Scribeberry, open Forms, search for immunization exemption or Statement of Medical Exemption, or upload the public-health PDF. Generate from the encounter and your notes, then review every field before you sign. Scribeberry does not pre-map this form. You still review and sign. Scribeberry does not file with the public health unit.
Frequently asked questions
Can I sign a religious or conscience exemption?
No as a medical act. Those processes (in Ontario, an education session plus a commissioned affidavit) are the parent’s. Your job is medical contraindication or immunity.
Is egg allergy a reason to skip MMR or influenza?
Follow current Canadian Immunization Guide and product monographs. Many egg-allergic children still receive those vaccines in the usual setting. Do not write a blanket exemption from a grocery-store egg story.
What about adults in healthcare jobs?
Employers and hospitals use their own medical-exemption processes. Complete that PDF. School ISPA forms are for pupils.
Does Scribeberry send this to public health?
No. Scribeberry helps you complete the PDF. The family files it with the health unit. Keep a copy in the chart.
Forms
