Exemptions – Forms -Tables

Release Form for Vaccine/Lab Telephone Consults pdf
To schedule a consult with Dr. Tenpenny or a healthcare professional at Tenpenny Integrative Medical Center, call 440-239-3438. Business hours are M->F, 9 to 5pEST.
Find a Holistic “vaccine friendly” Healthcare provider  pdf
Vaccine Tables
  • DTaP ingredients     pdf
  • DTaP death rates     pdf
  • Vaccines with Latex Stoppers                   pdf
  • Influenza vaccine ingredients  (table)     pdf
  • Why You Can Get the FLU SHOT and Still Get the FLU     pdf
  • Influenza vaccines, by manufacturer
    (a short comparison)     pdf
  • Influenza vs pneumonia; Death stats, 1999-2006     pdf
  • Charts documenting the decline of infectious disease (large file)     pdf
Sample Vaccine Refusal & Exemption Forms
  • Childcare and School Immunization Requirements This 39 page pdf contains State immunization policies that were validated in August, 2006. Document reflects state laws, regulations, or rules for vaccination requirements for enrollment and/or attendance in day care, Head Start, kindergarten, grades 1 through 12, colleges, and universities.  Some maps are included for comparison purposes.
  • Hep B vaccine in hospital for newborn refusal, sample  pdf
  • TB testing refusal, sample   pdf
  • OSHA Declination Statement Form     pdf
  • Religious exemption letter that was approved in Florida (Word) (pdf)
  • School Vaccine Exemption Form, sample (Word) (pdf)
  • Affidavit for Parents with International Adoption (Word) (pdf)
  • State Immunization Laws Searchable Database This tool contains results from a 50-state legislative review of laws requiring assessment of vaccination status and vaccine administration for healthcare workers and patients/residents.  The review was conducted by CDC and is current through November 2014, collected data on laws for the following types of facilities: hospitals, ambulatory care facilities, individual providers’ practices, correctional facilities, and facilities for the developmentally disabled.