Vaccine Exemption

“Adult & Child Vaccine Exemptions”

Vaccination & Immunity Consultation Services Offered:

Pediatric Vaccination Exemptions
Adult Vaccination Exemptions
Temporary Vaccination Exemptions

Due to a significant need that has been brought to our attention, we are now offering “Adult and Pediatric” consultations for Vaccination Exemptions. Adults may be impacted by the vaccination requirement when they seek to volunteer at their child’s school, in their work environment and a variety of other situations. If you find that you are being restricted from your routine activities due to your vaccination choices, please contact us to discuss your specific circumstances and we will do all that we can to assist you.

To schedule an appointment to discuss vaccinations and exemptions with Dr. William Clark, DO, please call (209) 838-3434.  Please complete all forms with as much detail as you can provide. ALL forms must be completed prior to your appointment. Families and patients arriving with incomplete paperwork will be re-scheduled and assessed a $200 re-scheduling fee. We have worked very hard to provide you with an abundance of information so that you can educate yourselves as much as possible prior to your visit with Dr. Clark. We want you to be an “informed” patient and make a decision that is in the best interest of your family.

Appointments are available on Tuesdays & Thursdays between the hours of 8:00am – 5:00pm, and closed from 12:00pm – 2:00pm for lunch.

If you find that you need a Vaccination Exemption immediately and are unable to schedule an appointment within a timely manner, there’s an option available to provide a Temporary Vaccination Exemption. A Temporary Exemption from our office would cover you for 60 days. During that time period, you must schedule a formal consultation with Dr. Clark to obtain a Permanent Exemption. The Process: complete all forms available online in their entirety and fax or email them back to our office. Note on the intake form that you are seeking a “Temporary” exemption and explain your circumstances. Once all forms are completed, signed and received in our office, they will be reviewed by Dr. Clark. If a vaccination exemption is medically indicated, then we will send you a temporary exemption form that again is only good for 60 days. They will not be extended for any reason. Next, you must schedule a formal face to face consultation with Dr. Clark to obtain any further exemptions.

The “Immunity Consultation New Patient Intake” Form & “Parental/Patient Acknowledgement and Agreement” Form are the same for pediatric, adult and temporary exemptions.

Contact Us
Office: (209) 838-3434
Fax: (209) 838-7753
Email: CONTACT@ESCALONPHYSICALMEDICINE.COM
Address: 1631 4th St., Escalon, CA 95320

FORMS

Immunity Consultation New Patient Intake Form

Parental Acknowledgement and Agreement Form

Preparing for Your Visit

Important Vaccine Definitions

Senate Bill No 277 SB277

Links to Vaccine Manufacture Drug Information

Vaccine Educational Resources

Vaccination Medical Exemption Letter

Office of the Governor – SB277 Explicitly Provides an Exception

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Cancellations made within 48 hours of the scheduled appointment will forfeit their $200 deposit.

No shows will forfeit their $200 deposit.

Arriving at your appointment without all paperwork completed will result in the appointment being re-scheduled and your $200 deposit will be forfeited.

Prices are subject to change without notice.