Sample Statement of Medical Exemption
COVID-19 Immunization- Public Use
Review the Medical Exemptions to COVID-19 Vaccination guidance prior to certifying a medical
exemption to ensure all criteria are met.
Section 1 – Individual Information
Last Name
First Name
DOB (yyyy/mm/dd)
Home Address
Unit Number Street Number
Street Name PO Box
City/Town Province Postal Code
Section 2 – Declaration of Physician or Registered Nurse in the Extended Class
(Nurse Practitioner)
I, ,
(Name of physician or registered nurse in the extended class)
certify that, for medical reasons, the above named individual is unable to receive a COVID-
19 immunization with the current COVID-19 vaccines available in Ontario (Pfizer-BioNTech
COVID-19 vaccine, Moderna COVID-19 vaccine, AstraZeneca/COVISHIELD COVID-19 vaccine).
Selection Condition and/or Adverse Event Following Immunization
1. Pre-existing Condition(s)
Severe allergic reaction or anaphylaxis to a component of a COVID-19 vaccine
Myocarditis prior to initiating a mRNA COVID-19 vaccine series (individuals aged 12-17
years old)
2. Contraindications to Initiating a AstraZeneca/ COVISHIELD COVID-19 Vaccine Series
History of capillary leak syndrome (CLS)
History of cerebral venous sinus thrombosis (CVST) with thrombocytopenia
History of heparin-induced thrombocytopenia (HIT)
History of major venous and/or arterial thrombosis with thrombocytopenia following
any vaccine
3. Adverse Events Following COVID-19 Immunization
Severe allergic reaction or anaphylaxis following a COVID-19 vaccine
Thrombosis with thrombocytopenia syndrome (TTS)/Vaccine-Induced Immune
Thrombotic Thrombocytopenia (VITT) following the Astra Zeneca/COVISHIELD
COVID-19 vaccine
Myocarditis or Pericarditis following a mRNA COVID-19 vaccine
Serious adverse event following immunization (e.g. results in hospitalization,
persistent or significant disability/incapacity)
4. Other
Actively receiving monoclonal antibody therapy OR convalescent plasma therapy for
the treatment or prevention of COVID-19
Section 3 - Length of Exemption
Permanent
Time
limited
From To
yyyy/mm/dd yyyy/mm/dd
Section 4 - Signature
Business Address
Unit Number Street Number Street Name PO Box
City/Town
Province
Postal Code
Signature of Physician or Registered Nurse in the
Extended Class
Designation Date (yyyy/mm/dd)
