Ontario's Ministry of Health uses the Statement of Medical Exemption (4895-64E) when a pupil needs a medical exemption from one or more vaccines required for school attendance under the Immunization of School Pupils Act. For each disease, the physician or nurse practitioner indicates immunity, through prior disease or laboratory confirmation, or a contraindication detrimental to health, and whether the exemption is permanent or temporary.
A physician or registered nurse in the extended class (nurse practitioner) completes the Section 2 declaration and signs Section 3 with their business address. Section 1 records the pupil's details, school name and class or grade.
Download the current version from the source each time; forms change without notice.
Statement of Medical Exemption - Immunization of School Pupils Act
Déclaration d'exemption médicale – Loi sur l'immunisation des élèves
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A physician or a registered nurse in the extended class (nurse practitioner). The Central Forms Repository says a physician or nurse practitioner must complete the Statement of Medical Exemption for children who need a medical exemption from vaccine requirements under the Immunization of School Pupils Act.
Immunity, shown by a clinical diagnosis of prior disease or by laboratory confirmation of immunity or prior disease, or a contraindication because the vaccine would be detrimental to health. Each exemption is marked permanent or temporary, with from and to dates for temporary ones.
Yes. The French version, Déclaration d'exemption médicale, Loi sur l'immunisation des élèves (4895-64F), is posted with the English form in Ontario's Central Forms Repository. The current English edition is 4895-64E (2025/04).