Yellow fever

Medical certificate for exemption from yellow fever vaccination

 

Patients name_____________________________________________________

 

Date of birth______________________________________________________

 

This is to certify that the above named person has not been vaccinated against YELLOW FEVER because af

 

□ Pregnancy

□ Less than 9 months of age

□ Other

 

Date                                                                                                                   Official stamp

 

Physicians’ signature_________________________________________________